Does machine perfusion improve immediate and short-term outcomes by enhancing graft function and recipient recovery after liver transplantation? A systematic review of the literature, meta-analysis and expert panel recommendations

BACKGROUND

Recent evidence supports the use of machine perfusion technologies (MP) for marginal liver grafts. Their effect on enhanced recovery, however, remains uncertain.

OBJECTIVES

To identify areas in which MP might contribute to an ERAS program and to provide expert panel recommendations.

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. CRD42021237713 RESULTS: Both hypothermic (HMP) and normothermic (NMP) machine perfusion demonstrated significant benefits in preventing postreperfusion syndrome (PRS) (HMP OR .33, .15-.75 CI; NMP OR .51, .29-.90 CI) and early allograft dysfunction (EAD) (HMP OR .51, .35-.75 CI; NMP OR .66, .45-.97 CI), while shortening LOS (HMP MD -3.9; NMP MD -12.41). Only NMP showed a significant decrease in the length of ICU stay (L-ICU) (MD -7.07, -8.76; -5.38 CI), while only HMP diminishes the likelihood of major complications. Normothermic regional perfusion (NRP) reduces EAD (OR .52, .38-.70 CI) and primary nonfunction (PNF) (OR .51, .27-.98 CI) without effect on L-ICU and LOS.

CONCLUSIONS

The use of HMP decreases PRS and EAD, specifically for marginal grafts. This is supported by a shorter LOS and a lower rate of major postoperative complications (QOE; moderate | Recommendation; Strong). NMP reduces the incidence of PRS and EAD with associated shortening in L-ICU for both DBD and DCD grafts (QOE; moderate | Recommendation; High) This technology also shortens the length of hospital stay (QOE; low | Recommendation; Strong). NRP decreases the likelihood of EAD (QOE; moderate) and the risk of PNF (QOE; low) when compared to both DBD and SRR-DCD grafts preserved in SCS. (Recommendation; Strong).

LAW Trial - The Impact of Local Anesthetics Infiltration in Surgical Wound for Gastrointestinal Procedures (LAW): A Double-Blind, Randomized Controlled Trial

INTRODUCTION AND AIMS

Prior studies have suggested that infiltration of local anesthetics reduce the rate of surgical site infections (SSIs). Opioid usage has become an epidemic. Some analgesic modalities, such as epidural analgesia and transversus abdominis plane block are associated with shorter length of stay and lower opioid use. The aim of our study was to assess the relationship between local infiltration of bupivacaine with rates of SSI and pain control.

MATERIALS AND METHODS

We conducted a prospective, double-blinded randomized controlled trial in patients who underwent open major gastrointestinal procedures from July 2016 to June 2017. Patients were divided into two groups based on administration of 0.5% bupivacaine (n = 30) (group 1) or placebo (n = 30) (control group). Outcomes evaluated were SSI, postoperative opioid requirements and pain scores.

RESULTS

Patients in the bupivacaine group required a lower dose of epidural analgesia during the first 24 h (5.3 mcg/kg/h vs. 6.4 mcg/kg/h; p = 0.05). Opioid requirement was shorter in the bupivacaine group (3.5 ± 2.3 days vs. 5.7 ± 2.9 days; p = 0.01). No difference was found between groups in terms of SSI rates (0% vs. 6.7%, p = 0.49).

CONCLUSIONS

There is no clear association between bupivacaine infiltration and reduction of SSI rate according to our study. Wound bupivacaine infiltration is associated with a lower dose of epidural infusion and opioid requirements.

Impact on quality of life after pancreatoduodenectomy: a prospective study comparing preoperative and postoperative scores

INTRODUCTION

Few studies compare the direct impact of pancreatoduodenectomy (PD) on the patient's quality of life (QOL). The effect of PD in QOL, comparing the preoperative vs. postoperative status, was analyzed.

METHOD

A prospective single-center study was performed. PD patients in a 2-year period were included. A general QOL instrument was applied preoperative, 1, 3, 6, and 12 months after surgery and compared with national norms.

RESULTS

Thirty-seven patients were recruited. Twenty of 37 were female. Ampullary carcinoma 14/37, ductal adenocarcinoma in 9/37, and other malignant neoplasms 14/37 were diagnosed. Mortality was absent; 48.6% had complications, 13.5 % required reoperation. Three (median) and 4 (mode) questionnaires were answered per individual. 85 % answered the last questionnaire. 4/37 had cancer related death before a year. Median follow-up was 29 (3-72) months. QOL diminished a month after surgery, physical function (67 vs 40, p<0.0001) and emotional role (37 vs 17, p<0.032) did so significantly. Three months after surgery QOL improved yet not significantly. Six and 12 months postoperatively, physical role (9 vs 49, p=0.001), physical pain (51 vs 71, p=0.01), social function (52 vs 63, p=0.014), vitality (54 vs 64, p=0.018), and emotional role (41 vs 69, p=0.006) improved significantly.

DISCUSSION

PD has a favorable impact in quality of life as demonstrated by the improvement of most parameters assessed in the postoperative period.