Anesthesia and Critical Care for the Prediction and Prevention for Small-for-size Syndrome: Guidelines from the ILTS-iLDLT-LTSI Consensus Conference.

BACKGROUND: During the perioperative period of living donor liver transplantation, anesthesiologists and intensivists may encounter patients in receipt of small grafts that puts them at risk of developing small for size syndrome (SFSS). METHODS: A scientific committee (106 members from 21 countries) performed an extensive literature review on aspects of SFSS with proposed recommendations. Recommendations underwent a blinded review by an independent expert panel and discussion/voting on the recommendations occurred at a consensus conference organized by the International Liver Transplantation Society, International Living Donor Liver Transplantation Group, and Liver Transplantation Society of India. RESULTS: It was determined that centers with experience in living donor liver transplantation should utilize potential small for size grafts. Higher risk recipients with sarcopenia, cardiopulmonary, and renal dysfunction should receive small for size grafts with caution. In the intraoperative phase, a restrictive fluid strategy should be considered along with routine use of cardiac output monitoring, as well as use of pharmacologic portal flow modulation when appropriate. Postoperatively, these patients can be considered for enhanced recovery and should receive proactive monitoring for SFSS, nutrition optimization, infection prevention, and consideration for early renal replacement therapy for avoidance of graft congestion. CONCLUSIONS: Our recommendations provide a framework for the optimal anesthetic and critical care management in the perioperative period for patients with grafts that put them at risk of developing SFSS. There is a significant limitation in the level of evidence for most recommendations. This statement aims to provide guidance for future research in the perioperative management of SFSS.

Proceedings of the 27th Annual Congress of the International Liver Transplantation Society.

After a virtual congress in 2021 and a previous absence in 2020 because of the coronavirus disease 2019 pandemic, the 27th Annual Congress of the International Liver Transplantation Society was held from May 4 to 7, 2022, in a hybrid format in Istanbul, with 1123 (58% on-site) liver transplant professionals from 61 countries attending the meeting. The hybrid format successfully achieved a balance of much yearned-for "in-person interaction" and global online participation. Almost 500 scientific abstracts were presented. In this report, the Vanguard Committee aims to present a summary of key invited lectures and selected abstracts for the liver transplant community.

Enhanced recovery for liver transplantation: recommendations from the 2022 International Liver Transplantation Society consensus conference.

There is much controversy regarding enhanced recovery for recipients of liver transplants from deceased and living donors. The objectives of this Review were to summarise current knowledge on individual enhanced recovery elements on short-term outcomes, identify key components for comprehensive pathways, and create internationally accepted guidelines on enhanced recovery for liver-transplant recipients. The ERAS4OLT.org collaborative partnered by the International Liver Transplantation Society performed systematic literature reviews on the effect of 32 relevant enhanced perioperative recovery elements on short-term outcomes, and global specialists prepared expert statements on deceased and living donor liver transplantation. The Grading Recommendations, Assessment, Development and Evaluations approach was used for rating of quality of evidence and grading of recommendations. A virtual international consensus conference was held in January, 2022, in which results were presented, voted on by the audience, and discussed by an independent international jury of eight members, applying the Danish model of consensus. 273 liver transplantation specialists from 30 countries prepared expert statements on elements of enhanced recovery for liver transplantation based on the systematic literature reviews. The consensus conference yielded 80 final recommendations, covering aspects of enhanced recovery for preoperative assessment and optimisation, intraoperative surgical and anaesthetic conduct, and postoperative management for the recipients of liver transplants from both deceased and living donors, and for the living donor. The recommendations represent a comprehensive overview of the relevant elements and areas of enhanced recovery for liver transplantation. These internationally established guidelines could direct the development of enhanced recovery programmes worldwide, allowing adjustments according to local resources and practices.

Are short-term complications associated with poor allograft and patient survival after liver transplantation? A systematic review of the literature and expert panel recommendations.

BACKGROUND: Maximizing patient and allograft survival after liver transplant (LT) is important from both a patient care and organ utilization perspective. Although individual studies have addressed the effects of short-term post-LT complications on a limited scale, there has not been a systematic review of the literature formally assessing the potential effects of early complications on long-term outcomes. OBJECTIVES: To identify whether short-term complications after LT affect allograft and overall survival, to identify short-term complications of particular clinical interest and significance, and to provide recommendations to improve post-LT graft and patient survival. DATA SOURCES: Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS: A systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. RESULTS: The literature review and analysis provided show that short-term complications have a large impact on allograft and patient survival after LT. The complications with the strongest effect on survival are acute kidney injury (AKI), biliary complications, and early allograft dysfunction (EAD). CONCLUSION: This panel recommends taking measures to reduce the risk and incidence of short-term complications post-LT. Clinicians should pay particular attention to preventing or ameliorating AKI, biliary complications, and EAD (Quality of evidence; Moderate | Grade of Recommendation; Strong).

Proceedings of the 26th Annual Virtual Congress of the International Liver Transplantation Society.

After a 1-y absence due to the coronavirus disease 2019 pandemic, the 26th Annual Congress of the International Liver Transplantation Society was held from May 15 to 18, 2021, in a virtual format. Clinicians and researchers from all over the world came together to share their knowledge on all the aspects of liver transplantation (LT). Apart from a focus on LT in times of coronavirus disease 2019, featured topics of this year's conference included infectious diseases in LT, living donation, machine perfusion, oncology, predictive scoring systems and updates in anesthesia/critical care, immunology, radiology, pathology, and pediatrics. This report presents highlights from invited lectures and a review of the select abstracts. The aim of this report, generated by the Vanguard Committee of International Liver Transplantation Society, is to provide a summary of the most recent developments in clinical practice and research in LT.

The role of acute in-patient rehabilitation on short-term outcomes after liver transplantation: A systematic review of the literature and expert panel recommendations.

BACKGROUND: The indication and surgical complexity of orthotopic liver transplantation underscore the need for strategies to optimize the recovery for transplant recipients. We conducted a systematic review aimed at identifying, evaluating, and synthesizing the evidence examining the effect of in-patient rehabilitation for liver transplant recipients and provide related practice recommendations. METHODS: Health research databases were systematically reviewed for studies that included adults who received liver transplantation and participated in acute, post-transplant rehabilitation. Postoperative morbidity, mortality, length of hospital stay, length of intensive care unit stay, and other markers of surgical recovery were extracted. Practice recommendations are provided by an international panel using GRADE. RESULTS: Twelve studies were included in the review (including 3901 participants). Rehabilitation interventions varied widely in design and composition; however, details regarding intervention delivery were poorly described in general. The quality of evidence was rated as very low largely owing to "very serious" imprecision, poor reporting, and limited data from comparative studies. Overall, the studies suggest that in-patient rehabilitation for recipients of liver transplantation is safe, tolerable, and feasible, and may benefit functional outcomes. CONCLUSION: Two practice recommendations related to in-patient rehabilitation following LT were yielded from this review: (1) it is safe, tolerable, and feasible; and (2) it improves postoperative functional outcomes. Each of the recommendations are weak and supported by low quality of evidence. No recommendation could be made related to benefits or harms for clinical, physiological, and other outcomes. Adequately powered and high quality randomized controlled trials are urgently needed in this area.

Which cava anastomotic techniques are optimal regarding immediate and short-term outcomes after liver transplantation: A systematic review of the literature and expert panel recommendations.

BACKGROUND: It has long been debated whether cava anastomosis should be performed with the piggyback technique or cava replacement, with or without veno-venous bypass (VVB), with or without temporary portocaval shunt (PCS) in the setting of liver transplantation. OBJECTIVES: To identify whether different cava anastomotic techniques and other maneuvers benefit the recipient regarding short-term outcomes and to provide international expert panel recommendations. DATA SOURCES: Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS: A systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel (CRD42021240979). RESULTS: Of 3205 records screened, 307 publications underwent full-text assessment for eligibility and 47 were included in qualitative synthesis. Four studies were randomized control trials. Eighteen studies were comparative. The remaining 25 were single-center retrospective noncomparative studies. CONCLUSION: Based on existing data and expert opinion, the panel cannot recommend one cava reconstruction technique over another, rather the surgical approach should be based on surgeon preference and center dependent, with special consideration toward patient circumstances (Quality of evidence: Low | Grade of Recommendation: Strong). The panel recommends against routine use of vevo-venous bypass (Quality of evidence: Very Low | Grade of Recommendation: Strong) and against the routine use of temporary porto-caval shunt (Quality of evidence: Very Low | Grade of Recommendation: Strong).

Influence of surgical technique in donor hepatectomy on immediate and short-term living donor outcomes - A systematic review of the literature, meta-analysis, and expert panel recommendations.

BACKGROUND: There are currently no guidelines pertaining to ERAS pathways in living donor hepatectomy. OBJECTIVES: The aim of this study was to identify whether surgical technique influences immediate and short-term outcomes after living liver donation surgery. DATA SOURCES: Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS: Systematic review and meta-analysis following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel (CRD42021260707). Endpoints were mortality, overall complications, serious complications, bile eaks, pulmonary complications, estimated blood loss and length of stay. RESULTS: Of the 2410 screened articles, 21 articles were included for final analysis; three observational, 13 retrospective cohort, four prospective cohort studies, and one randomized trial. Overall complications were higher with right versus left hepatectomy (26.8% vs. 20.8%; OR 1.4, P = .010). Donors after left hepatectomy had shorter length of stay (MD 1.4 days) compared to right hepatectomy. There was no difference in outcomes after right donor hepatectomy with versus without middle hepatic vein. We had limited data on the influence of incision type and minimally invasive approaches on living donor outcomes, and no data on the effect of operative time on donor outcomes. CONCLUSIONS: Left donor hepatectomy should be preferred over right hepatectomy, as it is related to improved donor short-term outcomes (QOE; Moderate | Grade of Recommendation; Strong). Right donor hepatectomy with or without MHV has equivalent outcomes (QOE; Moderate | Grade of Recommendation; Strong); no preference is recommended, decision should be based on program's experience and expertise. No difference in outcomes was observed related to incision type, minimally invasive vs. open (QOE; Low | Grade of Recommendation; Weak); no preference can be recommended.

Optimizing pre-donation physiologic evaluation for enhanced recovery after living liver donation - Systematic review and multidisciplinary expert panel recommendations.

BACKGROUND: While preoperative physiologic evaluation of live liver donors is routinely performed to ensure donor safety and minimize complications, the optimal approach to this evaluation is unknown. OBJECTIVES: We aim to identify predonation physiologic evaluation strategies to improve postoperative short-term outcomes, enhance donor's recovery, and reduce length of stay. We also aim to provide multidisciplinary expert panel recommendations. DATA SOURCES: Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS: The systematic review followed PRISMA guidelines, and the recommendations were formulated using GRADE approach and experts' opinion. The search included retrospective or prospective studies, describing outcomes of physiologic evaluation predonation. The outcomes of interest were length of stay, postoperative complications (POC), recovery after donation, and mortality. PROSERO protocol ID CRD42021260662. RESULTS: Of 1386 articles screened, only three retrospective cohort studies met eligibility criteria. Two studies demonstrated no impact of age (< 70 years) on POC. Increased body mass index's (BMI) association with POC was present in one study (23.8 vs 21.7 kg/m2 , OR 1.67 (1.14-2.48), P = .01) and absent in another (< 30 vs 30-35 kg/m2 , P = .61). One study demonstrated decreased risk for postdonation subclinical hepatic dysfunction in donors with higher normal platelet count (PLT). None of the studies noted donor death. Given the scarce data on predonation physiologic testing, the expert panel recommended a battery of tests to guide clinical practice and future investigations. CONCLUSION: Advancing age (60-69 years) is not a contraindication for liver donation. There is insufficient evidence for a specific predonation BMI cut-off. Abbreviated predonation physiologic testing is recommended in all candidates. Comprehensive testing is recommended in high-risk candidates while considering the pretest probability in various populations (Quality of evidence; Low to Very Low | Grade of Recommendation; Strong).

The role of T-tubes and abdominal drains on short-term outcomes in liver transplantation - A systematic review of the literature and expert panel recommendations.

BACKGROUND: This systematic review and expert panel recommendation aims to answer the question regarding the routine use of T-tubes or abdominal drains to better manage complications and thereby improve outcomes after liver transplantation. METHODS: Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel to assess the potential risks and benefits of T-tubes and intra-abdominal drainage in liver transplantation (CRD42021243036). RESULTS: Of the 2996 screened records, 33 studies were included in the systematic review, of which 29 (six RCTs) assessed the use of T-tubes and four regarding surgical drains. Although some studies reported less strictures when using a T-tube, there was a trend toward more biliary complications with T-tubes, mainly related to biliary leakage. Due to the small number of studies, there was a paucity of evidence on the effect of abdominal drains with no clear benefit for or against the use of drainage. However, one study investigating the open vs. closed circuit drains found a significantly higher incidence of intra-abdominal infections when open-circuit drains were used. CONCLUSIONS: Due to the potential risk of biliary leakage and infections, the routine intraoperative insertion of T-tubes is not recommended (Level of Evidence moderate - very low; grade of recommendation strong). However, a T-tube can be considered in cases at risk for biliary stenosis. Due to the scant evidence on abdominal drainage, no change in clinical practice in individual centers is recommended. (Level of Evidence very low; weak recommendation).

Information Asymmetry in Hospitals: Evidence of the Lack of Cost Awareness in Clinicians.

BACKGROUND: Information asymmetries and the agency relationship are two defining features of the healthcare system. These market failures are often used as a rationale for government intervention. Many countries have government financing and provision of healthcare in order to correct for this, while health technology agencies also exist to improve efficiency. However, informational asymmetries and the resulting principal-agent problem still persist, and one example is the lack of cost awareness amongst clinicians. This study explores the cost awareness of clinicians across different settings. METHODS: We targeted four clinical cohorts: medical students, Senior House Officers/Interns, Mid-grade Senior Registrar/Residents, and Consultant/Attending Physicians, in six hospitals in the United Kingdom, the United States, Australia, New Zealand and Spain. The survey asked respondents to report the cost (as they recalled) of different types of scans, visits, medications and tests. Our analysis focused on the differential between the perceived/recalled cost and the actual cost. We explored variation across speciality, country and other potential confounders. Cost-awareness levels were estimated based on the cost estimates within 25% of the actual cost. RESULTS: We received 705 complete responses from six sites across five countries. Our analysis found that respondents often overestimated the cost of common tests while underestimating high-cost tests. The mean cost-awareness levels varied between 4 and 23% for different items. Respondents acknowledged that they did not feel they had received adequate training in cost awareness. DISCUSSION: The current financial climate means that cost awareness and the appropriate use of scarce healthcare resources is more paramount than perhaps ever before. Much of the focus of health economics research is on high-cost innovative technologies, yet there is considerable waste in the system with respect to overtreatment and overdiagnosis. Common reasons put forward for this include defensive medicine, poor education, clinical uncertainty and the institution of protocols. CONCLUSION: Given the role of clinicians in the healthcare system, as agents both for patients and for providers, more needs to be done to remove informational asymmetries and improve clinician cost awareness.

The role of prehabilitation on short-term outcomes after liver transplantation: A review of the literature and expert panel recommendations.

BACKGROUND: Prehabilitation programs as part of ERAS protocols are being increasingly used in multiple surgeries, improving postoperative outcomes. Data regarding prehabilitation programs in patients awaiting liver transplantation and their outcomes is scarce. OBJECTIVES: To identify whether prehabilitation programs based on exercise training conducted prior to liver transplantation improve short-term postoperative outcomes, and to provide expert panel recommendations. DATA SOURCES: Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS: Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Studies included those evaluating postoperative outcomes, as well as those evaluating functional outcomes. PROSPERO ID: CRD42021236305. RESULTS: Of the 170 studies screened, only one assessed the primary objective. Most studies focus on the preoperative impact of exercise training on aerobic capacity, muscle mass and/or strength, showing positive effects and no significant adverse events, but are underpowered and with heterogenous designs and interventions. The non-randomized observational study which assessed relevant postoperative outcomes, showed a non-significant trend towards reduced 90-day readmission rate and shorter length of stay in the prehabilitation group. CONCLUSIONS: Prehabilitation prior to liver transplantation is unlikely to be harmful, and likely to have short term benefits on functional status. We cautiously recommend prehabilitation on the basis of absence of harm and possibility of benefit (Quality of Evidence; Very Low | Grade of Recommendation; Low).

Early removal of drains and lines after liver transplantation to reduce the length of hospital stay and enhance recovery - A systematic review of the literature and expert panel recommendations.

BACKGROUND: The timing of removing abdominal drains, central venous catheters (CVC), and urinary catheters (UC) on post liver transplantation (LT) outcomes is not well elucidated. OBJECTIVES: To provide international expert panel recommendations and guidelines on time of drain and catheter removal as a part of an ERAS protocol to reduce the length of hospital stay and enhance recovery. METHODS: Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Papers considered were those reporting one or more outcomes of interest related to drainage and line removal in the setting of LT. POSPERO Protocol ID: CRD42021238349 RESULTS: On analyzing five relevant studies pertaining to drains in patients undergoing LT (four retrospectives and one prospective), the length of hospital and/or ICU stay was similar or shorter, and postoperative morbidity and mortality were lower in those without drains. No studies pertaining specifically to the time of removal of drains, CVC's, or UC's in LT were found. Studies in patients undergoing major abdominal surgery or hepatectomies recommend early removal of CVC and UC to reduce catheter-associated infections. CONCLUSIONS: Based more on expert recommendation, we propose that abdominal drains, if placed during LT, should be removed by postoperative day 5 after LT, based on quantity and fluid characteristics (Quality of Evidence; Low to Moderate | Grade of Recommendation; Strong). Larger studies are needed to more reliably determine indications for early drain and line removal in an ERAS protocol setting.

What is the optimal prophylaxis against postoperative deep vein thrombosis in the living donor to avoid complications and enhance recovery? - A systematic review of the literature and expert panel recommendations.

BACKGROUND: Deep venous thrombosis (DVT) prophylaxis is often employed to prevent the potentially serious complication of pulmonary embolism (PE). However, little data exist regarding the optimal DVT prophylaxis strategy for living donors undergoing hepatectomy for living donor liver transplantation. Here we present our consensus statement on DVT prophylaxis for living donors undergoing hepatectomy. OBJECTIVES: To identify the optimal DVT prophylaxis strategy, which reduces, risk of complications in living liver donors, and enhances recovery. METHODS: Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Of interest was the impact of DVT prophylaxis or lack of prophylaxis on living donors undergoing hepatectomy and subsequent rates of DVT, PE, and hemorrhagic complications. PROSPERO ID: CRD42021260720 RESULTS: The review of the literature identified three studies, which directly addressed thrombogenesis following living donor hepatectomy. All studies were observational in nature without randomization into treatments. The rate of DVT-PE in unscreened living donors with chemoprophylaxis was 5%. Furthermore, thromboelastography of living donors demonstrated sustained hypercoagulability for 50% of donors 10 days postoperatively. In line with CHEST (The American College of Chest Physicians) guidelines of chemoprophylaxis for surgical procedures with 3% or greater risk of DVT-PE, we conclude that a minimum of 10 days of postoperative chemoprophylaxis with unfractionated heparin or low-molecular weight heparin is recommended for patients undergoing living donor hepatectomy. The quality of evidence (QOE) for these recommendations based on the GRADE criteria is low, with a Grade of Recommendation of Strong. CONCLUSIONS: Chemoprophylaxis for DVT following living donor hepatectomy is associated with reduced adverse thrombotic events, (Quality of Evidence; Low | Grade of Recommendation; Strong).

When is the optimal time to discharge patients after liver transplantation with respect to short-term outcomes? A systematic review of the literature and expert panel recommendations.

BACKGROUND: Several factors associated with prolonged hospital stay have been described. A recent study demonstrated that hospital length of stay (LOS) is directly associated with an increased cost for liver transplantation (LT) and may be associated with greater mortality; however, the factors associated with post-LT mortality are also related to a prolonged hospital stay, that is, those factors are confounders. Thus, the actual impact of the length of post-LT hospital stay on both short-term and long-term patient and graft survival remains uncertain. OBJECTIVES: To identify the optimal time to discharge patients after LT with respect to short-term outcomes; readmission rate, 30-90-mortality and morbidity. METHODS: Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Initial search keywords for screening were as follows; ((discharge AND (time OR "time point" OR "time-point")) OR "length of hospital stay" OR "length of stay") AND ((liver OR hepatic) AND (transplant OR transplantation)). PROSPERO ID: CRD42021245598 RESULTS: The strength of recommendation was rated as Weak, and we did not identify the direction of recommendations regarding the optimal timing after LT concerning short-term outcomes, including "Readmission rate," six studies on 30- and/or 90-day mortality, and five studies on "30- and/or 90-day morbidity rate." CONCLUSIONS: Evidence is scarce to judge the optimal timing to discharge patients after LT with respect to short-term outcomes. In centers with robust outpatient follow-up, discharge can occur safely as early as post-transplant 6-8 days (Quality of Evidence [QOE]; Low | Grade of Recommendation; Weak).

When is it safe for the liver donor to be discharged home and prevent unnecessary re-hospitalizations? - A systematic review of the literature and expert panel recommendations.

BACKGROUND: Few data are available on discharge criteria after living liver donation (LLD). OBJECTIVES: To identify the features for fit for discharge checklist after LLD to prevent unnecessary re-hospitalizations and to provide international expert recommendations. DATA SOURCES: Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS: Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. The critical outcomes included were complications rates and liver function (defined by elevated bilirubin and INR) (CRD42021260725). RESULTS: Total 57/1710 studies were included in qualitative analysis and 28/57 on the final analysis. No randomized controlled trials were identified. The complications rate was reported in 20/28 studies and ranged from 7.8% to 71.2%. Post hepatectomy liver function was reported in 13 studies. The Quality of Evidence (QoE) was Low and Very-Low for complications rate and liver function test, respectively. CONCLUSIONS: Monitoring and prevention of donor complications should be crucial in decision making of discharge. Pain and diet control, removal of all drains and catheters, deep venous thrombosis prophylaxis, and use routine imaging (CT scan or liver ultrasound) before discharge should be included as fit for discharge checklist (QoE; Low | GRADE of recommendation; Strong). Transient Impaired liver function (defined by elevated bilirubin and INR), a prognostic marker of outcome after liver resection, usually occurs after donor right hepatectomy and should be monitored. Improving trends for bilirubin and INR value should be observed by day 5 post hepatectomy and be included in the fit for discharge checklist. (QoE; Very-Low | GRADE; Strong).

The role of preoperative psychosocial counseling on the improvement of the recipient compliance and speed of recovery after liver transplantation - A systematic review of the literature and expert panel recommendations.

BACKGROUND: Psychosocial disorders ranging from anxiety to severe psychiatric diseases and active alcohol/substance abuse are frequent in liver transplant candidates and potentially associated with worse post- transplant outcomes. Therefore, psychosocial evaluation is mandatory to optimize success after liver transplantation. However, how to carry out this evaluation, the type of intervention needed and its potential impact on patient outcome remain unclear. OBJECTIVES: To investigate whether psychosocial assessment may help in predicting risks of poor outcome; and to investigate whether psychosocial interventions may mitigate these risks and improve posttransplant outcomes, in particular compliance and speed of recovery. DATA SOURCES: Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS: Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. The protocol was registered on PROSPERO CRD42021238361. Main outcomes assessed were mortality, alcohol relapse, rejection, and medication compliance. RESULTS: Fifteen studies were analyzed including five observational comparative and ten observational noncomparative studies. Preoperative psychosocial evaluation of LT candidates was associated with higher concordance with the treatment plan (i.e., higher adherence to treatment and lower alcohol relapse) and lower rates of rejection. Psychosocial assessment tools were used in some studies to guide the evaluation, but their predictive ability remains debated, and they should not be used in isolation. Most of the interventions were studied in patients with alcohol related issues. In this context, support by specialized teams was associated with better posttransplant outcome, especially through a decrease in post-transplant alcohol relapse. CONCLUSIONS: Preoperative psychosocial assessment should be provided in order to detect patients at increased risk of poorer post-transplant outcome, in particular in terms of concordance to the treatment plan (Quality of Evidence; Low | Grade of Recommendation; Strong/For). The experts suggest that, when possible, provision of preoperative psychological assessment and concomitant interventions aimed at improving the concordance to treatment plans will positively impact the success of liver transplantation. (Quality of Evidence; Very Low | Grade of Recommendation; Strong/For].

The role of early extubation on short-term outcomes after liver transplantation - A systematic review, meta-analysis and expert recommendations.

BACKGROUND: Early extubation in liver transplantation (LT) and its potential benefits such as reduction in pulmonary complications and enhanced postoperative recovery have been described. The extent of the effect of early extubation on short-term outcomes after LT across the published literature is to the best of our knowledge unknown. OBJECTIVES: The objective of this systematic review and meta-analysis was to determine whether early extubation improves immediate and short-term outcomes after LT and to provide expert recommendations. DATA SOURCES: Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS: A systematic review and meta-analysis on short-term outcomes after early extubation in LT was performed (CRD42021241402), following PRISMA guidelines and quality of evidence (QOE) and recommendations grading using the GRADE approach, derived from an international experts panel. Endpoints were reintubation rates, pulmonary and other complications/organ dysfunction, intensive care unit (ICU) and hospital length of stay (LOS). RESULTS: Of 831 screened articles, 20 observational studies with a total of 3573 patients addressing early extubation protocols were included, of which 12 studies compared results after early versus deferred extubation. Reintubation and pulmonary complication rates were lower in the early versus deferred extubation groups (OR 0.29, CI 0.22-0.39; OR 0.17, CI 0.09-0.33, respectively). ICU and hospital LOS were shorter in eight out of eight and seven out of eight comparative studies, respectively. CONCLUSIONS: Early extubation after LT is associated with improved short-term outcomes after LT and should be performed in the majority of patients (QOE; Moderate to low | Grade of Recommendation; Strong). Randomized controlled trials using standardized definitions of early extubation and short-term outcomes are needed to demonstrate causality, validate and allow comparability of the results.