Virtual Reality for Preoperative Planning in Complex Surgical Oncology: A Single-Center Experience.

INTRODUCTION: Virtual reality models (VRM) are three-dimensional (3D) simulations of two-dimensional (2D) images, creating a more accurate mental representation of patient-specific anatomy. METHODS: Patients were retrospectively identified who underwent complex oncologic resections whose operations differed from preoperative plans between April 2018 and April 2019. Virtual reality modeling was performed based on preoperative 2D images to assess feasibility of use of this technology to create models. Preoperative plans made based upon 2D imaging versus VRM were compared to the final operations performed. Once the use of VRM to create preoperative plans was deemed feasible, individuals undergoing complex oncologic resections whose operative plans were difficult to define preoperatively were enrolled prospectively from July 2019 to December 2021. Preoperative plans made based upon 2D imaging and VRM by both the operating surgeon and a consulting surgeon were compared to the operation performed. Confidence in each operative plan was also measured. RESULTS: Twenty patients were identified, seven retrospective and 13 prospective, with tumors of the liver, pancreas, retroperitoneum, stomach, and soft tissue. Retrospectively, VRM were unable to be created in one patient due to a poor quality 2D image; the remainder (86%) were successfully able to be created and examined. Virtual reality modeling more clearly defined the extent of resection in 50% of successful cases. Prospectively, all VRM were successfully performed. The concordance of the operative plan with VRM was higher than with 2D imaging (92% versus 54% for the operating surgeon and 69% versus 23% for the consulting surgeon). Confidence in the operative plan after VRM compared to 2D imaging also increased for both surgeons (by 15% and 8% for the operating and consulting surgeons, respectively). CONCLUSIONS: Virtual reality modeling is feasible and may improve preoperative planning compared to 2D imaging. Further investigation is warranted.

The impact of coronary artery disease on outcomes after liver transplantation.

AIMS: The aim of this study is to assess the impact of obstructive coronary artery disease (CAD) on outcomes after liver transplantation. BACKGROUND: Patients considered for liver transplantation are at an increased risk for CAD. Obstructive CAD is a contraindication for liver transplantation at most centres. However, the association between severity of CAD and liver transplantation outcomes remains poorly characterized. METHODS: We retrospectively reviewed 386 consecutive liver transplantations performed between January 2001 and December 2005 at Northwestern Memorial Hospital (NMH). A comparative analysis was conducted for a national cohort (n = 23 820) from the United Network for Organ Sharing database. Outcome measures included patient and graft survival, rates of acute myocardial infarction and heart failure. RESULTS: Patient survival remained similar irrespective of CAD severity or cardiovascular risk index (CRI) in the NMH cohort. The CRI closely correlated with the presence of CAD in the NMH cohort [CRI 0, odds ratio (OR) 0.125, 95% confidence interval (95% CI) 0.02-0.61, P = 0.01; CRI 1, OR 1 reference; CRI ≥2, OR 2.28, 95% CI 1.09-4.75, P = 0.02]. In the national cohort using Cox regression, high (≥2) CRI (reference 0, hazard ratio 1.376, 95% CI 1.271-1.488, P < 0.0001) predicted patient mortality and exceeded established risk factors, including Hepatitis C virus (HCV) (hazard ratio 1.321, 95% CI 1.242-1.403, P < 0.0001), hepatocellular carcinoma (HCC) (hazard ratio 1.27, 95% CI 1.181-1.370, P < 0.0001) and diabetes (hazard ratio 1.241, 95% CI 1.160-1.326, P < 0.0001). CONCLUSION: Liver transplantation in patients with CAD is not associated with prohibitive risk for cardiac events and patient mortality. Appropriately treated CAD should therefore not represent a contraindication to liver transplantation.

Clinical outcomes and quality of life in recipients of livers donated after cardiac death.

Donation after cardiac death (DCD) has expanded in the last decade in the US; however, DCD liver utilization has flattened in recent years due to poor outcomes. We examined clinical and quality of life (QOL) outcomes of DCD recipients by conducting a retrospective and cross-sectional review of patients from 2003 to 2010. We compared clinical outcomes of DCD recipients (n = 60) to those of donation after brain death (DBD) liver recipients (n = 669) during the same time period. DCD recipients had significantly lower rates of 5-year graft survival (P < 0.001) and a trend toward lower rates of 5-year patient survival (P = 0.064) when compared to the DBD cohort. In order to examine QOL outcomes in our cohorts, we administered the Short Form Liver Disease Quality of Life questionnaire to 30 DCD and 60 DBD recipients. The DCD recipients reported lower generic and liver-specific QOL. We further stratified the DCD cohort by the presence of ischemic cholangiopathy (IC). Patients with IC reported lower QOL when compared to DBD recipients and those DCD recipients without IC (P < 0.05). While the results are consistent with clinical experience, this is the first report of QOL in DCD recipients using standardized measures. These data can be used to guide future comparative effectiveness studies.

Comparative effectiveness of donation after cardiac death versus donation after brain death liver transplantation: Recognizing who can benefit.

Due to organ scarcity and wait-list mortality, transplantation of donation after cardiac death (DCD) livers has increased. However, the group of patients benefiting from DCD liver transplantation is unknown. We studied the comparative effectiveness of DCD versus donation after brain death (DBD) liver transplantation. A Markov model was constructed to compare undergoing DCD transplantation with remaining on the wait-list until death or DBD liver transplantation. Differences in life years, quality-adjusted life years (QALYs), and costs according to candidate Model for End-Stage Liver Disease (MELD) score were considered. A separate model for hepatocellular carcinoma (HCC) patients with and without MELD exception points was constructed. For patients with a MELD score <15, DCD transplantation resulted in greater costs and reduced effectiveness. Patients with a MELD score of 15 to 20 experienced an improvement in effectiveness (0.07 QALYs) with DCD liver transplantation, but the incremental cost-effectiveness ratio (ICER) was >$2,000,000/QALY. Patients with MELD scores of 21 to 30 (0.25 QALYs) and >30 (0.83 QALYs) also benefited from DCD transplantation with ICERs of $478,222/QALY and $120,144/QALY, respectively. Sensitivity analyses demonstrated stable results for MELD scores <15 and >20, but the preferred strategy for the MELD 15 to 20 category was uncertain. DCD transplantation was associated with increased costs and reduced survival for HCC patients with exception points but led to improved survival (0.26 QALYs) at a cost of $392,067/QALY for patients without exception points. In conclusion, DCD liver transplantation results in inferior survival for patients with a MELD score <15 and HCC patients receiving MELD exception points, but provides a survival benefit to patients with a MELD score >20 and to HCC patients without MELD exception points.

A comprehensive risk assessment of mortality following donation after cardiac death liver transplant - an analysis of the national registry.

BACKGROUND & AIMS: Organ scarcity has resulted in increased utilization of donation after cardiac death (DCD) donors. Prior analysis of patient survival following DCD liver transplantation has been restricted to single institution cohorts and a limited national experience. We compared the current national experience with DCD and DBD livers to better understand survival after transplantation. METHODS: We compared 1113 DCD and 42,254 DBD recipients from the Scientific Registry of Transplant Recipients database between 1996 and 2007. Patient survival was analyzed using the Kaplan-Meier methodology and Cox regression. RESULTS: DCD recipients experienced worse patient survival compared to DBD recipients (p<0.001). One and 3 year survival was 82% and 71% for DCD compared to 86% and 77% for DBD recipients. Moreover, DCD recipients required re-transplantation more frequently (DCD 14.7% vs. DBD 6.8%, p<0.001), and re-transplantation survival was markedly inferior to survival after primary transplant irrespective of graft type. Amplification of mortality risk was observed when DCD was combined with cold ischemia time >12h (HR = 1.81), shared organs (HR = 1.69), recipient hepatocellular carcinoma (HR=1.80), recipient age >60 years (HR = 1.92), and recipient renal insufficiency (HR = 1.82). CONCLUSIONS: DCD recipients experience significantly worse patient survival after transplantation. This increased risk of mortality is comparable in magnitude to, but often exacerbated by other well-established risk predictors. Utilization decisions should carefully consider DCD graft risks in combination with these other factors.

Ischemic cholangiopathy after controlled donation after cardiac death liver transplantation: a meta-analysis.

OBJECTIVE: To conduct a meta-analysis to enhance understanding of the risks of biliary complications, particularly ischemic cholangiopathy (IC), after donation after cardiac death (DCD) compared with donation after brain death (DBD) liver transplantation. BACKGROUND: Biliary complications after liver transplantation have profound health and economic implications which merit further investigation. METHODS: The MEDLINE (1950­2009), EMBASE, and Cochrane Library databases were searched and supplemented by review of conference proceedings and publication bibliographies. All original single institution studies reporting outcomes for DCD and DBD liver transplant recipients were considered. Odds ratios (OR) and 95% confidence intervals (CI) based on random effects models were calculated. RESULTS: Eleven publications, all retrospective cohort studies, involving 489 DCD and 4455 DBD recipients, were included. Donation after cardiac death recipients had a 2.4 times increased odds of biliary complications (95% CI= 1.8­3.4) and a 10.8 times increased odds of IC (95% CI = 4.8­24.2).Ischemic cholangiopathy was present in 16% of DCD compared with 3% of DBD recipients. Donation after cardiac death recipients also experienced higher odds of 1-year patient mortality (OR = 1.6, 95% CI = 1.04­2.5) and graft failure (OR = 2.1, 95% CI = 1.5­2.8). CONCLUSIONS: Donation after cardiac death liver transplantation is marred by inferior outcomes including higher rates of biliary complications and IC as well as increased mortality and graft failure. Despite current federal mandates to increase DCD donation, these serious complications translate into poor outcomes for individuals and increased healthcare costs. These risks should be considered in decisions regarding the utilization of these grafts.

The increased costs of donation after cardiac death liver transplantation: caveat emptor.

OBJECTIVE: To determine the effect of donation after cardiac death (DCD) livers on post-transplantation costs. BACKGROUND: DCD livers are increasingly being used to expand the donor pool despite higher complication rates. Although complications after liver transplantation have profound financial implications, the effect of DCD livers on post-transplantation costs has not been studied. METHODS: We estimated direct medical care costs based on inpatient and outpatient hospital costs for 28 DCD and 198 donation after brain death (DBD) liver recipients. Organ acquisition and physician costs were excluded. RESULTS: Donor and recipient demographics were comparable for DCD and DBD transplants. One-year, post-transplantation costs were higher for DCD recipients (124.9% of DBD costs, P = 0.04). DCD costs remained higher (125.2% of DBD costs, P = 0.009) after adjusting for recipient characteristics. Furthermore, DCD post-transplantation costs were 30% higher than DBD costs after adjusting for pre-transplantation costs (P = 0.02). Biliary complications (DCD 58% vs. DBD 21%; P < 0.001) and, specifically, ischemic cholangiopathy (DCD 44% vs. DBD 1.6%; P < 0.001) occurred more frequently after DCD transplantation. Moreover, DCD recipients underwent retransplantation more often (DCD 21% vs. DBD 7.1%, P = 0.02). One-year costs were increased for recipients with ischemic cholangiopathy or retransplantation by 53% (P = 0.01) and 107% (P < 0.001), respectively. However, DCD costs continued to be higher when retransplanted patients were excluded (120% of DBD costs, P = 0.02). CONCLUSIONS: Higher rates of graft failure and biliary complications translate into markedly increased direct medical care costs for DCD recipients. These important financial implications should be considered in decisions regarding the use of DCD livers.

The impact of ischemic cholangiopathy in liver transplantation using donors after cardiac death: the untold story.

BACKGROUND: Liver transplantation (LT) from donation after cardiac death (DCD) donors is increasingly being used to address organ shortages. Despite encouraging reports, standard survival metrics have overestimated the effectiveness of DCD livers. We examined the mode, kinetics, and predictors of organ failure and resource utilization to more fully characterize outcomes after DCD LT. METHODS: We reviewed the outcomes for 32 DCD and 237 donation after brain death (DBD) LT recipients at our institution. RESULTS: Recipients of DCD livers had a 2.1 times greater risk of graft failure, a 2.5 times greater risk of relisting, and a 3.2 times greater risk of retransplantation compared with DBD recipients. DCD recipients had a 31.6% higher incidence of biliary complications and a 35.8% higher incidence of ischemic cholangiopathy. Ischemic cholangiography was primarily implicated in the higher risk of graft failure observed after DCD LT. DCD recipients with ischemic cholangiography experienced more frequent rehospitalizations, longer hospital stays, and required more invasive biliary procedures. CONCLUSION: Related to higher complication rates, DCD recipients necessitated greater resource utilization. This more granular data should be considered in the decision to promote DCD LT. Modification of liver allocation policy is necessary to address those disadvantaged by a failing DCD graft.