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Richards JA, Gaurav R, Upponi SS, Swift L, Fear C, Webb GJ, Allison MED, Watson CJE, Butler AJ. Outcomes of livers from donation after circulatory death donors with extended agonal phase and the adjunct of normothermic regional perfusion. Br J Surg 2023; 110:1112-1115. [PMID: 37079886 PMCID: PMC10416677 DOI: 10.1093/bjs/znad099] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/18/2023] [Accepted: 03/27/2023] [Indexed: 04/22/2023]
Abstract
The liver performs important functions that are essential for life. If the liver fails, patients will die unless they receive a new liver from a donor (transplant). Unfortunately, there are not enough livers for everyone and some patients die while waiting for a suitable organ. This article describes a novel technique that allows resuscitation and testing of a potential donor liver so that more patients can safely receive a transplant.
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Affiliation(s)
- James A Richards
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
- University of Cambridge Department of Surgery, Addenbrooke’s Hospital, Cambridge, UK
- NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK
- National Institute for Health and Care Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
- HPB and Liver Transplant Surgery, Royal Free Hospital, London, UK
| | - Rohit Gaurav
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
- National Institute for Health and Care Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Sara S Upponi
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
- National Institute for Health and Care Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
| | - Lisa Swift
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
| | - Corrina Fear
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
| | - Gwilym J Webb
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
- Department of Medicine, Cambridge University Hospitals, Addenbrooke’s Hospital, Cambridge, UK
| | - Michael E D Allison
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
- National Institute for Health and Care Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
- Department of Medicine, Cambridge University Hospitals, Addenbrooke’s Hospital, Cambridge, UK
| | - Christopher J E Watson
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
- University of Cambridge Department of Surgery, Addenbrooke’s Hospital, Cambridge, UK
- NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK
- National Institute for Health and Care Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Andrew J Butler
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
- University of Cambridge Department of Surgery, Addenbrooke’s Hospital, Cambridge, UK
- NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK
- National Institute for Health and Care Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
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Biliary Complications After Liver Transplantation in the United States: Changing Trends and Economic Implications. Transplantation 2023; 107:e127-e138. [PMID: 36928182 DOI: 10.1097/tp.0000000000004528] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND Biliary complications (BCs) continue to impact patient and graft survival after liver transplant (LT), despite improvements in organ preservation, surgical technique, and posttransplant care. Real-world evidence provides a national estimate of the incidence of BC after LT, implications for patient and graft outcomes, and attributable cost not available in transplant registry data. METHODS An administrative health claims-based BC identification algorithm was validated using electronic health records (N = 128) and then applied to nationally linked Medicare and transplant registry claims. RESULTS The real-world evidence algorithm identified 97% of BCs in the electronic health record review. Nationally, the incidence of BCs within 1 y of LT appears to have improved from 22.2% in 2002 to 20.8% in 2018. Factors associated with BCs include donor type (living versus deceased), recipient age, diagnosis, prior transplant, donor age, and donor cause of death. BCs increased the risk-adjusted hazard ratio (aHR) for posttransplant death (aHR, 1.43; P < 0.0001) and graft loss (aHR, 1.48; P < 0.0001). Nationally, BCs requiring intervention increased risk-adjusted first-year Medicare spending by $39 710 (P < 0.0001). CONCLUSIONS BCs remain an important cause of morbidity and expense after LT and would benefit from a systematic quality-improvement program.
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3
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Biliary complications following split liver transplantation in adult recipients: a matched pair analysis on single-center experience. Liver Transpl 2023; 29:279-289. [PMID: 36811877 DOI: 10.1097/lvt.0000000000000058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 10/21/2022] [Indexed: 02/24/2023]
Abstract
The utilization of split liver grafts can increase access to liver transplantation (LT) for adult patients, particularly when liver grafts are shared between 2 adult recipients. However, it is yet to be determined whether split liver transplantation (SLT) increases the risk of biliary complications (BCs) compared with whole liver transplantation (WLT) in adult recipients. This retrospective study enrolled 1441 adult patients who underwent deceased donor LT at a single-site between January 2004 and June 2018. Of those, 73 patients underwent SLTs. Graft type for SLT includes 27 right trisegment grafts, 16 left lobes, and 30 right lobes. A propensity score matching analysis selected 97 WLTs and 60 SLTs. Biliary leakage was more frequently seen in SLTs (13.3% vs. 0%; p <0.001), whereas the frequency of biliary anastomotic stricture was comparable between SLTs and WLTs (11.7% vs. 9.3%; p=0.63). Graft and patient survival rates of patients undergoing SLTs were comparable to those undergoing WLTs (p=0.42 and 0.57, respectively). In the analysis of the entire SLT cohort, BCs were seen in 15 patients (20.5%) including biliary leakage in 11 patients (15.1%) and biliary anastomotic stricture in 8 patients (11.0%) [both in 4 patients (5.5%)]. The survival rates of recipients who developed BCs were significantly inferior to those without BCs (p <0.01). By multivariate analysis, the split grafts without common bile duct increased the risk of BCs. In conclusion, SLT increases the risk of biliary leakage compared with WLT. Biliary leakage can still lead to fatal infection and thus should be managed appropriately in SLT.
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Impact of side-to-side cavocavostomy versus traditional piggyback implantation in liver transplantation. Surgery 2020; 168:1060-1065. [DOI: 10.1016/j.surg.2020.07.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/18/2020] [Accepted: 07/12/2020] [Indexed: 02/06/2023]
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Richards JA, Sherif AE, Butler AJ, Hunt F, Allison M, Oniscu GC, Watson CJE. Model for early allograft function is predictive of early graft loss in donation after circulatory death liver transplantation. Clin Transplant 2020; 34:e13982. [PMID: 32441409 DOI: 10.1111/ctr.13982] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 05/06/2020] [Accepted: 05/16/2020] [Indexed: 12/17/2022]
Abstract
Donation after circulatory death (DCD) liver transplantation is associated with higher rates of graft loss. In this paper, we explored whether the Model for Early Allograft Function (MEAF) predicted outcome in DCD liver transplantation. We performed a retrospective analysis of prospectively collected data from all adult DCD (Maastricht 3) livers transplanted in Cambridge and Edinburgh between 1 January 2011 and 30 June 2017, excluding those undergoing any form of machine perfusion. 187 DCD liver transplants were performed during the study period. DCD liver transplants with a lower MEAF score had a significantly better survival compared to those with a high MEAF score (Mantel-Cox P < .0001); this was largely due to early graft loss. Beyond 28 days post-transplant, there were no significant long-term graft or patient survival differences irrespective of the grade of MEAF (Mantel-Cox P = .64 and P = .43, respectively). The MEAF score correlated with the length of ICU (P = .0011) and hospital stay (P = .0007), but did not predict the requirement for retransplantation for ischemic cholangiopathy (P = .37) or readmission (P = .74). In this study, a high MEAF score predicted early graft loss, but not the subsequent need for re-transplantation or late graft failure as a result of intrahepatic ischemic bile duct pathology.
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Affiliation(s)
- James A Richards
- University of Cambridge Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,The NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK.,The National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Ahmed E Sherif
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andrew J Butler
- University of Cambridge Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,The NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK.,The National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
| | - Fiona Hunt
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Michael Allison
- The National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK.,Department of Medicine, Cambridge University Hospitals, Addenbrooke's Hospital, Cambridge, UK
| | - Gabriel C Oniscu
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK.,Department of Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Christopher J E Watson
- University of Cambridge Department of Surgery, Addenbrooke's Hospital, Cambridge, UK.,The NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK.,The National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, Cambridge, UK
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Postsurgical Management of Dilated Biliary Tract in Children: Ultrasound-Guided Percutaneous Transhepatic Cholangial Drainage and Subsequent Percutaneous Ultrasound Cholangiography. AJR Am J Roentgenol 2020; 214:1377-1383. [PMID: 32160054 DOI: 10.2214/ajr.19.22225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE. The purpose of this study was to evaluate the feasibility of ultrasound (US)-guided percutaneous transhepatic cholangial drainage (PTCD) and consequent percutaneous US cholangiography in managing the dilated biliary tracts of children who have undergone hepatobiliary surgery. SUBJECTS AND METHODS. Sixteen children (11 boys, five girls; age range, 3-144 months) who underwent hepatobiliary surgery from December 2016 to October 2018 and had US evidence of biliary dilatation were included. All patients had undergone US-guided PTCD because of elevated postoperative serum bilirubin levels or bile duct infection. Immediately after the PTCD procedure, diluted sulphur hexafluoride microbubbles dispersion was injected through the PTCD tube to evaluate the anastomosis and the intrahepatic bile duct tree. Laboratory results, including those of serum bilirubin measurement, liver function tests, and routine blood tests, were evaluated before and after PTCD. Nine of 16 patients also underwent percutaneous transhepatic cholangiography (PTC). The percutaneous US cholangiography findings were evaluated and compared with the PTC findings. RESULTS. Liver enzyme levels decreased after PTCD with a statistically significant difference from the values before PTCD. Percutaneous US cholangiography showed that the anastomosis in 6 of the 16 patients (37.5%) was patent and depicted the morphologic featuresof intrahepatic bile duct tree in five of these patients. In the other 10 patients, the anastomosis was completely obstructed, and percutaneous US cholangiography depicted the morphologic features of intrahepatic bile duct tree in eight patients. In the nine patients who underwent PTC, the percutaneous US cholangiographic findings were the same as the PTC findings. CONCLUSION. US-guided PTCD is helpful in relieving jaundice and inflammation in children who have undergone hepatobiliary surgery and have biliary dilatation. Findings at consequent percutaneous US cholangiography are comparable to those of PTC in depicting the anastomosis in these patients.
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7
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Lebovitz EE, Nguyen AVT, Sakai T. Economic considerations in abdominal transplantation. Best Pract Res Clin Anaesthesiol 2020; 34:15-23. [DOI: 10.1016/j.bpa.2020.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 12/26/2019] [Accepted: 01/08/2020] [Indexed: 12/16/2022]
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Liu Y, Sun LY, Zhu ZJ, Wei L, Qu W, Zeng ZG. Bile microbiota: new insights into biliary complications in liver transplant recipients. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:354. [PMID: 32355798 PMCID: PMC7186729 DOI: 10.21037/atm.2020.02.60] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Biliary complications represent a major problem associated with liver transplantation. This report represents the first study to use high-throughput 16S ribosomal RNA (rRNA) gene sequencing to assess bile microbiota within bile samples of liver transplant recipients with biliary complications. Our goal in this report was to identify the species and abundance of microbes and examine the potential for microbial involvement of bile in liver transplantation patients with biliary complications. Methods Liver transplant recipients treated at our center over the period from September 2015 to June 2017 were enrolled in the study. Patients satisfying the inclusion criteria were divided into two groups, control (N=13) and symptom (N=10). Sequencing of 16s rDNA was then performed on bile samples from both groups. Results The main bacterial phyla of bile samples in the symptom group included Proteobacteria (55.19%), Firmicutes (32.36%), Actinobacteria (10.24%) and Bacteroidetes (1.23%) and the main bacterial genera were Pseudomonas (23.31%), Klebsiella (18.42%), Lactococcus (9.61%), Rhodococcus (9.59%) and Rhizobium (5.08%). Proteobacteria and Staphylococcus were enriched in the symptom group (P<0.05), whereas Firmicutes (P<0.05) and Enterococcus (P<0.01) were enriched in the control group. Pathways involved as determined with use of the Kyoto Encyclopedia of Genes and Genomes (KEGG), revealed that metabolism pathways of glyoxylate and dicarboxylate, porphyrin and chlorophyll, arginine and proline, glycine, serine and threonine, as well as the bacterial secretion system were all enriched in bile samples from the symptom group (P<0.05). Conclusions Clear differences exist in microbial species distribution in bile samples from the symptom versus control group. The species and pathways enriched in bile samples within the symptom group may be involved in the pathogenesis of biliary complication after liver transplantation.
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Affiliation(s)
- Ying Liu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Li-Ying Sun
- Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Zhi-Jun Zhu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Lin Wei
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Wei Qu
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Zhi-Gui Zeng
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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Staged Biliary Reconstruction After Orthotopic Liver Transplantation: A Practical Surgical Strategy for High-Acuity Adult Recipients. Transplant Direct 2019; 5:e482. [PMID: 31579810 PMCID: PMC6739041 DOI: 10.1097/txd.0000000000000924] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 06/23/2019] [Accepted: 06/24/2019] [Indexed: 01/12/2023] Open
Abstract
Biliary complications (BC) following orthotopic liver transplantation (OLT) is strongly associated with inferior patient outcomes and increased healthcare cost. BC in high-acuity patients can be lethal. While the utility of staged biliary reconstruction after liver transplantation (SBRALT) has been reported in adult and pediatric OLT, biliary outcome data are scarce. We sought to evaluate the clinical utility and outcomes of SBRALT in high-acuity transplant recipients. Methods We conducted an analysis from our prospective database of 149 adult OLT between January 1, 2012, and September 30, 2017. Mean follow-up was 26 months. Variables were compared for Group I: one-stage OLT with biliary reconstruction (N = 58) versus Group II: SBRALT (N = 91). Results Compared with Group I, patients in Group II had higher acuity of illness: median model for end-stage liver disease scores (19 vs 35 P = 0.002), requirement for pretransplant intensive care unit (29.3% vs 54.9%, P = 0.022), pretransplant renal replacement therapy (15.5% vs 48.4%), estimated blood loss (2000 vs 4750 mL, P < 0.001), and intraoperative packed red blood cells transfusion (4 vs 10 units, P < 0.001). For Group II, biliary reconstruction was performed between 1 and 6 days after OLT. Hepaticojejunostomy was performed in 8.6% (Group I) and 26.4% (Group II), P = 0.010. For Groups I and II, BC rates (8.6% vs 7.7%, P = 0.955) and 1-year graft failure-free survival rates (89.7% vs 88.2%, P = 0.845) were comparable. Conclusions Graft failure-free survival and biliary outcomes of SBRALT in high-acuity recipients are excellent and comparable to one-stage OLT for low-risk patients. SBRALT is a practical surgical strategy in complex OLT.
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10
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Taylor R, Allen E, Richards JA, Goh MA, Neuberger J, Collett D, Pettigrew GJ. Survival advantage for patients accepting the offer of a circulatory death liver transplant. J Hepatol 2019; 70:855-865. [PMID: 30639505 DOI: 10.1016/j.jhep.2018.12.033] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 12/17/2018] [Accepted: 12/19/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND & AIMS Donation after circulatory death (DCD) in the UK has tripled in the last decade. However, outcomes following DCD liver transplantation are worse than for donation after brainstem death (DBD) liver transplants. This study examines whether a recipient should accept a "poorer quality" DCD organ or wait longer for a "better" DBD organ. METHODS Data were collected on 5,825 patients who were registered on the elective waiting list for a first adult liver-only transplant and 3,949 patients who received a liver-only transplant in the UK between 1 January 2008 and 31 December 2015. Survival following deceased donor liver transplantation performed between 2008 and 2015 was compared by Cox regression modelling to assess the impact on patient survival of accepting a DCD liver compared to deferring for a potential DBD transplant. RESULTS A total of 953 (23%) of the 3,949 liver transplantations performed utilised DCD donors. Five-year post-transplant survival was worse following DCD than DBD transplantation (69.1% [DCD] vs. 78.3% [DBD]; p <0.0001: adjusted hazard ratio [HR] 1.65; 95% CI 1.40-1.94). Of the 5,798 patients registered on the transplant list, 1,325 (23%) died or were removed from the list without receiving a transplant. Patients who received DCD livers had a lower risk-adjusted hazard of death than those who remained on the waiting list for a potential DBD organ (adjusted HR 0.55; 95% CI 0.47-0.65). The greatest survival benefit was in those with the most advanced liver disease (adjusted HR 0.19; 95% CI 0.07-0.50). CONCLUSIONS Although DCD liver transplantation leads to worse transplant outcomes than DBD transplantation, the individual's survival is enhanced by accepting a DCD offer, particularly for patients with more severe liver disease. DCD liver transplantation improves overall survival for UK listed patients and should be encouraged. LAY SUMMARY This study looks at patients who require a liver transplant to save their lives; this liver can be donated by a person who has died either after their heart has stopped (donation after cardiac death [DCD]) or after the brain has been injured and can no longer support life (donation after brainstem death [DBD]). We know that livers donated after brainstem death function better than those after cardiac death, but there are not enough of these livers for everyone, so we wished to help patients decide whether it was better for them to accept an early offer of a DCD liver than waiting longer to receive a "better" liver from a DBD donor. We found that patients were more likely to survive if they accepted the offer of a liver transplant as soon as possible (DCD or DBD), especially if their liver disease was very severe.
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Affiliation(s)
- Rhiannon Taylor
- Statistics and Clinical Studies, NHS Blood and Transplant, Fox Den Road, Stoke Gifford, Bristol BS34 8RR, United Kingdom
| | - Elisa Allen
- Statistics and Clinical Studies, NHS Blood and Transplant, Fox Den Road, Stoke Gifford, Bristol BS34 8RR, United Kingdom
| | - James A Richards
- University Department of Surgery, Addenbrooke's Hospital, Hill Road, Cambridge CB2 0QQ, United Kingdom
| | - Mingzheng A Goh
- University Department of Surgery, Addenbrooke's Hospital, Hill Road, Cambridge CB2 0QQ, United Kingdom
| | - James Neuberger
- University Hospital Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham B15 2TH, United Kingdom
| | - David Collett
- Statistics and Clinical Studies, NHS Blood and Transplant, Fox Den Road, Stoke Gifford, Bristol BS34 8RR, United Kingdom
| | - Gavin J Pettigrew
- University Department of Surgery, Addenbrooke's Hospital, Hill Road, Cambridge CB2 0QQ, United Kingdom.
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Kim J, Zimmerman MA, Lerret SM, Scott JP, Voulgarelis S, Fons RA, Vitola BE, Telega GW, Hoffman GM, Berens RJ, Hong JC. Staged biliary reconstruction after liver transplantation: A novel surgical strategy for high acuity pediatric transplant recipients. Surgery 2019; 165:323-328. [DOI: 10.1016/j.surg.2018.08.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 08/16/2018] [Accepted: 08/28/2018] [Indexed: 12/28/2022]
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12
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Vivalda S, Zhengbin H, Xiong Y, Liu Z, Wang Z, Ye Q. Vascular and Biliary Complications Following Deceased Donor Liver Transplantation: A Meta-analysis. Transplant Proc 2019; 51:823-832. [PMID: 30979471 DOI: 10.1016/j.transproceed.2018.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 11/15/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess biliary and vascular complications after liver transplantations (LTs) sourced from deceased donors. METHODS This study reviewed potentially relevant English-language articles gathered from PubMed and Medline published from 2012 to 2017. One additional study was carried out using our institution's database for articles published from 2013 to 2017. Biliary and vascular complications from adult patients receiving their first deceased-donor LT were included. This meta-analysis was performed using Review Manager version 5.2 (Cochrane Collaboration, Copenhagen, Denmark) and the study quality was evaluated using the Newcastle-Ottawa Scale. RESULTS Ten studies met our inclusion criteria. Heterogeneity in donation after cardiac death (DCD) and donation after brain death (DBD) recipients was observed and minimized after pooling a subgroup analysis. This latter analysis focused on biliary stricture, biliary leaks and stones, and vascular thrombosis and stenosis. Meta-analyses showed that patients receiving DCD organs have a greatly increased risk of biliary complications compared to those receiving DBD organs, particularly the following: biliary leaks and stones (odds ratio [OR] = 1.69, 95% confidence interval [CI] 1.22-2.34); and biliary stricture (OR = 1.58, 95% CI 1.21-2.06). DCD grafts tended to be but were not significantly associated with DBD regarding vascular thrombosis (OR = 1.62, 95% CI 1.05-2.50), and the risk of vascular stenosis in DCD grafts was not statistically significant (OR = 1.25, 95% CI, .70-2.25). CONCLUSION DCD was associated with an increased risk of biliary complications after LT, tended to indicate an increased risk of vascular thrombosis versus, and was not associated with an increased risk of vascular stenosis compared to DBD. There was no significant difference between the grafts.
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Affiliation(s)
- S Vivalda
- Institute of Hepatobiliary Diseases, Transplant Center, Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - H Zhengbin
- Institute of Hepatobiliary Diseases, Transplant Center, Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Y Xiong
- Institute of Hepatobiliary Diseases, Transplant Center, Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Z Liu
- Institute of Hepatobiliary Diseases, Transplant Center, Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Z Wang
- Institute of Hepatobiliary Diseases, Transplant Center, Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Q Ye
- Institute of Hepatobiliary Diseases, Transplant Center, Hubei Key Laboratory of Medical Technology on Transplantation, Zhongnan Hospital, Wuhan University, Wuhan, China; Transplantation Medicine Engineering and Technology Research Center, National Health Commission, the 3rd Xiangya Hospital of Central South University, Changsha, China.
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13
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Liao FM, Chang MH, Ho MC, Chen HL, Ni YH, Hsu HY, Wu JF. Resistance index of hepatic artery can predict anastomotic biliary complications after liver transplantation in children. J Formos Med Assoc 2019; 118:209-214. [DOI: 10.1016/j.jfma.2018.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 03/23/2018] [Accepted: 03/27/2018] [Indexed: 02/07/2023] Open
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14
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Fleming JN, Taber DJ, Axelrod D, Chavin KD. The effect of Share 35 on biliary complications: An interrupted time series analysis. Am J Transplant 2019; 19:221-226. [PMID: 29767478 DOI: 10.1111/ajt.14937] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 05/08/2018] [Accepted: 05/10/2018] [Indexed: 01/25/2023]
Abstract
The purpose of the Share 35 allocation policy was to improve liver transplant waitlist mortality, targeting high MELD waitlisted patients. However, policy changes may also have unintended consequences that must be balanced with the primary desired outcome. We performed an interrupted time series assessing the impact of Share 35 on biliary complications in a select national liver transplant population using the Vizient CDB/RM database. Liver transplants that occurred between October 2012 and September 2015 were included. There was a significant change in the incident-rate of biliary complications between Pre-Share 35 (n = 3018) and Post-Share 35 (n = 9984) cohorts over time (P = .023, r2 = .44). As a control, a subanalysis was performed throughout the same time period in Region 9 transplant centers, where a broad sharing agreement had previously been implemented. In the subanalysis, there was no change in the incident-rate of biliary complications between the two time periods. Length of stay and mean direct cost demonstrated a change after implementation of Share 35, although they did not meet statistical difference. While the target of improved waitlist mortality is of utmost importance for the equitable allocation of organs, unintended consequences of policy changes should be studied for a full assessment of a policy's impact.
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Affiliation(s)
- J N Fleming
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, SC, USA
| | - D J Taber
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA.,Department of Pharmacy, Ralph H. Johnson VAMC, Charleston, South Carolina, USA
| | - D Axelrod
- Department of Transplantation, Lahey Medical Center, Burlington, MA, USA
| | - K D Chavin
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA.,Department of Surgery, University Hospitals Cleveland Medical Center, Case Western School of Medicine, Cleveland, OH, USA
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Bhutiani N, Jones JM, Wei D, Goldstein LJ, Martin RCG, Jones CM, Cannon RM. A cost analysis of early biliary strictures following orthotopic liver transplantation in the United States. Clin Transplant 2018; 32:e13396. [PMID: 30160322 DOI: 10.1111/ctr.13396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 08/20/2018] [Accepted: 08/25/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION To date, the financial burden of biliary strictures (BS) after orthotopic liver transplantation (OLT) has remained largely unassessed. This study sought to approximate perioperative costs associated with early BS and delineate where in the hospital these costs are incurred. METHODS The Premier Healthcare Database was queried for patients undergoing OLT between 2010 and 2016. Patients who did and did not develop early BS were compared with respect to perioperative costs and outcome variables. Multivariable regression models were used to estimate differences between groups. RESULTS Patients who developed early BS had a longer length of stay (LOS) (35.3 days vs 17.8 days, P < 0.001) and were less likely to be discharged home (odds ratio = 0.45, P = 0.003). Development of early BS was associated with an incremental cost increase of $81 881 (45.8%, P < 0.001). The greatest relative cost increases were in radiology (+163.5%) and respiratory therapy (+157.1%), while the greatest absolute increase was in room and board (+$27 589). CONCLUSIONS Early BS after OLT result in higher costs stemming from longer LOS and increased need for various diagnostic studies and therapies. In addition to incentivizing measures that may prevent early BS, hospitals should account for these factors when developing payment schemes for OLT with payors.
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Affiliation(s)
- Neal Bhutiani
- Division of Transplantation, Hiram C. Polk Jr, MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Jordan M Jones
- Division of Transplantation, Hiram C. Polk Jr, MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - David Wei
- Epidemiology, Medical Devices, Johnson & Johnson, New Brunswick, New Jersey
| | - Laura J Goldstein
- Franchise Health Economics and Market Access, Ethicon, Somerville, New Jersey
| | - Robert C G Martin
- Division of Transplantation, Hiram C. Polk Jr, MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Christopher M Jones
- Division of Transplantation, Hiram C. Polk Jr, MD Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Robert M Cannon
- Division of Transplantation, Hiram C. Polk Jr, MD Department of Surgery, University of Louisville, Louisville, Kentucky
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Severe Unresolved Cholestasis Due to Unknown Etiology Leading to Early Allograft Failure Within the First 3 Months of Liver Transplantation. Transplantation 2018; 102:1307-1315. [DOI: 10.1097/tp.0000000000002139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Mogul DB, Luo X, Bowring MG, Chow EK, Massie AB, Schwarz KB, Cameron AM, Bridges JFP, Segev DL. Fifteen-Year Trends in Pediatric Liver Transplants: Split, Whole Deceased, and Living Donor Grafts. J Pediatr 2018; 196:148-153.e2. [PMID: 29307689 PMCID: PMC5924625 DOI: 10.1016/j.jpeds.2017.11.015] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 10/10/2017] [Accepted: 11/03/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate changes in patient and graft survival for pediatric liver transplant recipients since 2002, and to determine if these outcomes vary by graft type (whole liver transplant, split liver transplant [SLT], and living donor liver transplant [LDLT]). STUDY DESIGN We evaluated patient and graft survival among pediatric liver-only transplant recipients the PELD/MELD system was implemented using the Scientific Registry of Transplant Recipients. RESULTS From 2002-2009 to 2010-2015, survival for SLT at 30 days improved (94% vs 98%; P < .001), and at 1 year improved for SLT (89% to 95%; P <.001) and LDLT (93% to 98%; P = .002). There was no change in survival for whole liver transplant at either 30 days (98% in both; P = .7) or 1 year (94% vs 95%; P = .2). The risk of early death with SLT was 2.14-fold higher in 2002-2009 (adjusted hazard ratio [aHR] vs whole liver transplant, 1.472.143.12), but this risk disappeared in 2010-2015 (aHR, 0.651.131.96), representing a significant improvement (P = .04). Risk of late death after SLT was similar in both time periods (aHR 2002-2009, 0.871.141.48; aHR 2010-2015, 0.560.881.37). LDLT had similar risk of early death (aHR 2002-2009, 0.491.032.14; aHR 2010-2015, 0.260.742.10) and late death (aHR 2002-2009, 0.520.831.32; aHR 2010-2015, 0.170.441.11). Graft loss was similar for SLT (aHR, 0.931.091.28) and was actually lower for LDLT (aHR, 0.530.710.95). CONCLUSIONS In recent years, outcomes after the use of technical variant grafts are comparable with whole grafts, and may be superior for LDLT. Greater use of technical variant grafts might provide an opportunity to increase organ supply without compromising post-transplant outcomes.
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Affiliation(s)
- Douglas B Mogul
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Xun Luo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mary G Bowring
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eric K Chow
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allan B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
| | - Kathleen B Schwarz
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew M Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John F P Bridges
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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18
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A literature-based cost analysis of tissue plasminogen activator for prevention of biliary stricture in donation after circulatory death liver transplantation. Am J Surg 2018; 216:959-962. [PMID: 29724406 DOI: 10.1016/j.amjsurg.2018.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 04/02/2018] [Accepted: 04/11/2018] [Indexed: 01/08/2023]
Abstract
INTRODUCTION This study sought to approximate the cost-effectiveness of tPA utilization for prevention of biliary strictures (PTBS) in donation after circulatory death liver transplantation (DCD-LT). METHODS Previously-reported PTBS rates in DCD-LT with and without tPA were used to calculate the number needed to treat (NNT) for prevention of one PTBS. The incremental cost of PTBS was then used to determine the cost effectiveness of tPA for prevention of PTBS. RESULTS The incidence of PTBS in the setting of tPA administration was 20%, while incidence in patients without tPA use was 43% (p < 0.001). Meta-analysis demonstrated a risk reduction of 15.7%, which translated into a NNT of 6.4. Cost associated with treating 6.4 patients was $50,353. Based on an incremental cost of $81,888 associated with PTBS management, use of tPA in DCD-LT protocols was estimated to save $31,528 per PTBS prevented. CONCLUSION Utilization of tPA in DCD-LT protocols represents one possible cost-effective strategy for prevention of PTBS in DCD-LT.
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19
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Lin LM, Kuo SC, Chiu YC, Lin HF, Kuo ML, Elsarawy AM, Chen CL, Lin CC. Cost Analysis and Determinants of Living Donor Liver Transplantation in Taiwan. Transplant Proc 2018; 50:2601-2605. [PMID: 30401359 DOI: 10.1016/j.transproceed.2018.03.061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/02/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Liver transplantation (LT) has become established therapy for end-stage liver disease and small-cell hepatocellular carcinoma (HCC), relying mainly on living donor LT (LDLT) in Taiwan. The cost of LDLT varies in different countries depending on the insurance system, the costs of the facility, and staff. In this study we aimed to investigate cost outcomes and determinants of LDLT in Taiwan. METHODS From January 2014 to December 2015, 184 LDLT patients were enrolled in a study performed at the Kaohsiung Chang Gung Memorial Hospital. Patients' transplantation costs were defined as expense from immediately after surgery to discharge during hospitalization for LDLT. Antiviral therapy and hepatitis B immunoglobulin (HBIG) for prevention of hepatitis B virus (HBV) were included, but direct-acting antiviral (DAA) therapy for hepatitis C (HCV) was excluded. RESULTS The median total, intensive care unit (ICU), and ward costs of LT were US$64,250, $43,357, and $16,138 (currency ratio 1:30), respectively. HBV significantly increased the total cost of LT, followed by postoperative reintubation and bile duct complications. CONCLUSION The charges associated with anti-HBV viral therapy and HBIG increase the cost of LDLT. Disease severity of liver cirrhosis showed less importance in predicting cost. Postoperative complications such as reintubation or bile duct complications should be avoided to reduce the cost of LT.
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Affiliation(s)
- L-M Lin
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - S-C Kuo
- Department of Surgery, Liver Transplantation Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Y-C Chiu
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - H-F Lin
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - M-L Kuo
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - A M Elsarawy
- Department of Surgery, Liver Transplantation Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - C-L Chen
- Department of Surgery, Liver Transplantation Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - C-C Lin
- Department of Surgery, Liver Transplantation Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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20
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Dhar VK, Wima K, Kim Y, Hoehn RS, Jung AD, Ertel AE, Diwan TS, Paterno F, Shah SA. Cost of achieving equivalent outcomes in sicker patients after liver transplant. HPB (Oxford) 2018; 20:268-276. [PMID: 28988703 DOI: 10.1016/j.hpb.2017.08.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/10/2017] [Accepted: 08/30/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND We aimed to characterize variability in cost after straightforward orthotopic liver transplant (OLT). METHODS Using the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases, we identified patients who underwent OLT between 2011 and 2014. Patients meeting criteria for straightforward OLT, defined as length of stay < 14 days with discharge to home, were selected (n = 5763) and grouped into tertiles (low, medium, high) according to cost of perioperative stay. RESULTS Patients undergoing straightforward OLT were of similar demographics regardless of cost. High cost patients were more likely to require preoperative hemodialysis, had higher severity of illness, and higher model for end-stage liver disease (MELD) (p < 0.01). High cost patients required greater utilization of resources including lab tests, blood transfusions, and opioids (p < 0.01). Despite having higher burden of disease and requiring increased resource utilization, high cost OLT patients with a straightforward perioperative course were shown to have identical 2-year graft and overall survival compared to lower cost patients (p = 0.82 and p = 0.63), respectively. CONCLUSION Providing adequate perioperative care for OLT patients with higher severity of illness and disease burden requires increased cost and resource utilization; however, doing so provides these patients with long term survival equivalent to more routine patients.
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Affiliation(s)
- Vikrom K Dhar
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Koffi Wima
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Young Kim
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Richard S Hoehn
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew D Jung
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Audrey E Ertel
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tayyab S Diwan
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Flavio Paterno
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shimul A Shah
- Cincinnati Research on Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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21
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Forrest EA, Reiling J, Lipka G, Fawcett J. Risk factors and clinical indicators for the development of biliary strictures post liver transplant: Significance of bilirubin. World J Transplant 2017; 7:349-358. [PMID: 29312864 PMCID: PMC5743872 DOI: 10.5500/wjt.v7.i6.349] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 09/18/2017] [Accepted: 11/02/2017] [Indexed: 02/05/2023] Open
Abstract
AIM To identify risk factors associated with the formation of biliary strictures post liver transplantation over a period of 10-year in Queensland.
METHODS Data on liver donors and recipients in Queensland between 2005 and 2014 was obtained from an electronic patient data system. In addition, intra-operative and post-operative characteristics were collected and a logistical regression analysis was performed to evaluate their association with the development of biliary strictures.
RESULTS Of 296 liver transplants performed, 285 (96.3%) were from brain dead donors. Biliary strictures developed in 45 (15.2%) recipients. Anastomotic stricture formation (n = 25, 48.1%) was the commonest complication, with 14 (58.3%) of these occurred within 6-mo of transplant. A percutaneous approach or endoscopic retrograde cholangiography was used to treat 17 (37.8%) patients with biliary strictures. Biliary reconstruction was initially or ultimately required in 22 (48.9%) patients. In recipients developing biliary strictures, bilirubin was significantly increased within the first post-operative week (Day 7 total bilirubin 74 μmol/L vs 49 μmol/L, P = 0.012). In both univariate and multivariate regression analysis, Day 7 total bilirubin > 55 μmol/L was associated with the development of biliary stricture formation. In addition, hepatic artery thrombosis and primary sclerosing cholangitis were identified as independent risk factors.
CONCLUSION In addition to known risk factors, bilirubin levels in the early post-operative period could be used as a clinical indicator for biliary stricture formation.
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Affiliation(s)
- Elizabeth Ann Forrest
- Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Queensland 4102, Australia
- Department of Surgery, Gold Coast Hospital and Health Service, Gold Coast, Queensland 4215, Australia
| | - Janske Reiling
- Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Queensland 4102, Australia
- Faculty of Medicine, the University of Queensland, Brisbane, Queensland 4006, Australia
- Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, Queensland 4120, Australia
- Department of Surgery, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, AZ Maastricht 6202, The Netherlands
- PA Research Foundation, Princess Alexandra Hospital, Brisbane, Queensland 4102, Australia
| | - Geraldine Lipka
- Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Queensland 4102, Australia
| | - Jonathan Fawcett
- Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Queensland 4102, Australia
- Faculty of Medicine, the University of Queensland, Brisbane, Queensland 4006, Australia
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22
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Flores A, Asrani SK. The donor risk index: A decade of experience. Liver Transpl 2017; 23:1216-1225. [PMID: 28590542 DOI: 10.1002/lt.24799] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 05/22/2017] [Accepted: 05/24/2017] [Indexed: 02/07/2023]
Abstract
In 2006, derivation of the donor risk index (DRI) highlighted the importance of donor factors for successful liver transplantation. Over the last decade, the DRI has served as a useful metric of donor quality and has enhanced our understanding of donor factors and their impact upon recipients with hepatitis C virus, those with low Model for End-Stage Liver Disease (MELD) score, and individuals undergoing retransplantation. DRI has provided the transplant community with a common language for describing donor organ characteristics and has served as the foundation for several tools for organ risk assessment. It is a useful tool in assessing the interactions of donor factors with recipient factors and their impact on posttransplant outcomes. However, limitations of statistical modeling, choice of donor factors, exclusion of unaccounted donor and geographic factors, and the changing face of the liver transplant recipient have tempered its widespread use. In addition, the DRI was derived from data before the MELD era but is currently being applied to expand the donor pool while concurrently meeting the demands of a dynamic allocation system. A decade after its introduction, DRI remains relevant but may benefit from being updated to provide guidance in the use of extended criteria donors by accounting for the impact of geography and unmeasured donor characteristics. DRI could be better adapted for recipients with nonalcoholic fatty liver disease by examining and including recipient factors unique to this population. Liver Transplantation 23 1216-1225 2017 AASLD.
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Affiliation(s)
- Avegail Flores
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO
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Liver Preservation by Aortic Perfusion Alone Compared With Preservation by Aortic Perfusion and Additional Arterial Ex Situ Back-Table Perfusion With Histidine-Tryptophan-Ketoglutarate Solution: A Prospective, Randomized, Controlled, Multicenter Study. Transplant Direct 2017; 3:e183. [PMID: 28706986 PMCID: PMC5498024 DOI: 10.1097/txd.0000000000000686] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 04/03/2017] [Indexed: 12/14/2022] Open
Abstract
Background Arterial ex situ back-table perfusion (BP) reportedly reduces ischemic-type biliary lesion after liver transplantation. We aimed to verify these findings in a prospective investigation. Methods Our prospective, randomized, controlled, multicenter study involved livers retrieved from patients in 2 German regions, and compared the outcomes of standard aortic perfusion to those of aortic perfusion combined with arterial ex situ BP. The primary endpoint was the incidence of ischemic-type biliary lesions over a follow-up of 2 years after liver transplantation, whereas secondary endpoints included 2-year graft survival, initial graft damage as reflected by transaminase levels, and functional biliary parameters at 6 months after transplantation. Results A total of 75 livers preserved via standard aortic perfusion and 75 preserved via standard aortic perfusion plus arterial BP were treated using a standardized protocol. The incidence of clinically apparent biliary lesions after liver transplantation (n = 9 for both groups; P = 0.947), the 2-year graft survival rate (standard aortic perfusion, 74%; standard aortic perfusion plus arterial BP, 68%; P = 0.34), and incidence of initial graft injury did not differ between the 2 perfusion modes. Although 33 of the 77 patients with cholangiography workups exhibited injured bile ducts, only 10 had clinical symptoms. Conclusions Contrary to previous findings, the present study indicated that additional ex situ BP did not prevent ischemic-type biliary lesions or ischemia-reperfusion injury after liver transplantation. Moreover, there was considerable discrepancy between cholangiography findings regarding bile duct changes and clinically apparent cholangiopathy after transplantation, which should be considered when assessing ischemic-type biliary lesions.
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Agopian VG. Liver transplantation with donation after cardiac death donors as a strategy for recipients with model for end-stage liver disease score >15: Has the die been cast? Liver Transpl 2017; 23:579-580. [PMID: 28296066 DOI: 10.1002/lt.24756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 02/27/2017] [Indexed: 01/13/2023]
Affiliation(s)
- Vatche G Agopian
- Division of Liver Transplantation, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
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25
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Coelho JCU, Leite LDO, Molena A, Freitas ACTD, Matias JEF. BILIARY COMPLICATIONS AFTER LIVER TRANSPLANTATION. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2017; 30:127-131. [PMID: 29257849 PMCID: PMC5543792 DOI: 10.1590/0102-6720201700020011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/04/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Biliary reconstitution has been considered the Achilles's heel of liver transplantations due to its high rate of postoperative complications. AIM To evaluate the risk factors for occurrence of biliary strictures and leakages, and the most efficient methods for their treatment. METHOD Of 310 patients who underwent liver transplantation between 2001 and 2015, 182 medical records were retrospectively analyzed. Evaluated factors included demographic profile, type of transplantation and biliary reconstitution, presence of vascular and biliary complications, their treatment and results. RESULTS 153 (84.07%) deceased donor and 29 (15.93%) living donor transplantations were performed. Biliary complications occurred in 49 patients (26.92%): 28 strictures (15.38%), 14 leakages (7.7%) and seven leakages followed by strictures (3.85%). Hepatic artery thrombosis was present in 10 patients with biliary complications (20.4%; p=0,003). Percutaneous and endoscopic interventional procedures (including balloon dilation and stent insertion) were the treatment of choice for biliary complications. In case of radiological or endoscopic treatment failure, surgical intervention was performed (biliodigestive derivation or retransplantation (32.65%). Complications occurred in 25% of patients treated with endoscopic or percutaneous procedures and in 42.86% of patients reoperated. Success was achieved in 45% of patients who underwent endoscopic or percutaneous procedures and in 61.9% of those who underwent surgery. CONCLUSION Biliary complications are frequent events after liver transplantation. They often require new interventions: endoscopic and percutaneous procedures at first and surgical treatment when needed. Hepatic artery thrombosis increases the number of biliary complications.
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Affiliation(s)
| | | | - Antonio Molena
- Department of Surgery, Clinics Hospital, Federal University of Paraná, Curitiba, PR, Brazil
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26
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Minneman JA, Grijalva JL, LaQuaglia MJ, Kim HB, Rangel SJ, Vakili K. Variation in resource utilization in liver transplantation at freestanding children's hospitals. Pediatr Transplant 2016; 20:921-925. [PMID: 27762480 DOI: 10.1111/petr.12783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/21/2016] [Indexed: 11/30/2022]
Abstract
We sought to examine the relationship between liver transplant-related total cost, patient outcome, and hospital resource utilization at freestanding children's hospitals. Using the PHIS database, a retrospective study of 374 patients that underwent liver transplantation at 15 freestanding children's hospitals from July 2010 to December 2012 was performed. One-year graft failure and patient mortality rates from July 2010 to December 2012 for each center were also obtained from the SRTR. There was a 5.1-fold difference in median cost (median $146 444, range $59 487-302 058, P<.001) between all centers. A 2.4-fold difference existed in median LOS (median 15 days, range 9-22 days, P<.001) across centers. Median postoperative ICU stay varied from 0 to 7 days (median 4 days, P<.001). Overall, 30-day readmission rate was 55% (31.3%-100%, P<.001). One-year graft failure varied from 0% to 19.1%, with an overall rate of 5.5% (P=.279). One-year patient mortality for all centers was 2.3% (range 0%-11.1%, P=.016). Higher total cost did not correlate with lower readmission rates, patient mortality, graft failure, or any other variable. These data suggest that identifying practice patterns at low-cost centers and implementing them at higher-cost centers may decrease the cost of pediatric liver transplantation without compromising outcomes.
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Affiliation(s)
| | - James L Grijalva
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | | | - Heung Bae Kim
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Khashayar Vakili
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA.
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Györi GP, Schwarzer R, Püspök A, Schöfl R, Silberhumer GR, Langer FB, Trauner M, Peck-Radosavljevic M, Berlakovich GA, Ferlitsch A. Endoscopic versus surgical management of biliary complications - Outcome analysis after 1188 orthotopic liver transplantations. Dig Liver Dis 2016; 48:1323-1329. [PMID: 27311881 DOI: 10.1016/j.dld.2016.05.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 04/18/2016] [Accepted: 05/17/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM After liver transplantation, the endoscopic approach has become the standard treatment modality for biliary complications. Aim of this study was to compare primary endoscopic with primary surgical management. PATIENTS AND METHODS A retrospective review on 1188 consecutive liver transplant patients between 1989 and 2009 was performed. Management strategies (endoscopic, surgical or combined approach) were evaluated for treatment success as well as patient survival. RESULTS Biliary complications after liver transplantation were diagnosed in 211 (18%) patients. Initial endoscopic approach (N=162, 77%) was successful in 97 of 162 (60%) patients. In 80% of patients, success was achieved within a median of four ERCPs. Sixty-one patients (38%) were referred to surgery after non-successful ERCP. Initial surgical approach was performed in 49/211 patients (23%) with successful management in 38/49 (78%) of patients. Patients presenting with intraluminal objects needed a significantly higher number of ERCPs to reach treatment success (median 3 versus 2 interventions, p=0.001) but had an equal endoscopic success rate (p=0.427). Patients with successful endoscopic treatment showed lower mortality compared to patients with primary surgical treatment (p=0.029). CONCLUSIONS Endoscopic management should be considered as the primary approach for biliary complications after liver transplantation.
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Affiliation(s)
- Georg P Györi
- Department of Surgery, Division of Transplantation, Medical University Vienna, Vienna, Austria
| | - Remy Schwarzer
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University Vienna, Vienna, Austria
| | - Andreas Püspök
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University Vienna, Vienna, Austria
| | - Rainer Schöfl
- Department of Internal Medicine IV, Krankenhaus der Elisabethinen Linz, Austria
| | - Gerd R Silberhumer
- Department of Surgery, Division of Transplantation, Medical University Vienna, Vienna, Austria
| | - Felix B Langer
- Department of Surgery, Division of Transplantation, Medical University Vienna, Vienna, Austria
| | - Michael Trauner
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University Vienna, Vienna, Austria
| | - Markus Peck-Radosavljevic
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University Vienna, Vienna, Austria
| | - Gabriela A Berlakovich
- Department of Surgery, Division of Transplantation, Medical University Vienna, Vienna, Austria
| | - Arnulf Ferlitsch
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University Vienna, Vienna, Austria.
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28
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Analysis of Factors Associated With Biliary Complications in Children After Liver Transplantation. Transplantation 2016; 100:1944-54. [DOI: 10.1097/tp.0000000000001298] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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29
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Irwin FD, Wu C, Bannister WM, Bonagura AF, Laihinen B, Axelrod DA, Schnitzler MA. A commercial transplant network's perspective of value in solid organ transplantation: Strategizing for value in transplant care. Transplant Rev (Orlando) 2016; 30:71-6. [DOI: 10.1016/j.trre.2015.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 11/10/2015] [Indexed: 10/22/2022]
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30
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Inflammatory genes in rat livers from cardiac- and brain death donors. J Surg Res 2015; 198:217-27. [DOI: 10.1016/j.jss.2015.04.057] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Revised: 04/07/2015] [Accepted: 04/15/2015] [Indexed: 12/14/2022]
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31
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Equalizing MELD Scores Over Broad Geographies Is Not the Most Efficacious Way to Allocate a Scarce Resource in a Value-based Environment. Ann Surg 2015; 262:220-3. [DOI: 10.1097/sla.0000000000001331] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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