Recent outcomes of liver transplantation for Budd-Chiari syndrome: A study of the European Liver Transplant Registry (ELTR) and affiliated centers

BACKGROUND AND AIMS

Management of Budd-Chiari syndrome (BCS) has improved over the last decades. The main aim was to evaluate the contemporary post-liver transplantant (post-LT) outcomes in Europe.

APPROACH AND RESULTS

Data from all patients who underwent transplantation from 1976 to 2020 was obtained from the European Liver Transplant Registry (ELTR). Patients < 16 years with secondary BCS or HCC were excluded. Patient survival (PS) and graft survival (GS) before and after 2000 were compared. Multivariate Cox regression analysis identified predictors of PS and GS after 2000. Supplemental data was requested from all ELTR-affiliated centers and received from 44. In all, 808 patients underwent transplantation between 2000 and 2020. One-, 5- and 10-year PS was 84%, 77%, and 68%, and GS was 79%, 70%, and 62%, respectively. Both significantly improved compared to outcomes before 2000 ( p < 0.001). Median follow-up was 50 months and retransplantation rate was 12%. Recipient age (aHR:1.04,95%CI:1.02-1.06) and MELD score (aHR:1.04,95%CI:1.01-1.06), especially above 30, were associated with worse PS, while male sex had better outcomes (aHR:0.63,95%CI:0.41-0.96). Donor age was associated with worse PS (aHR:1.01,95%CI:1.00-1.03) and GS (aHR:1.02,95%CI:1.01-1.03). In 353 patients (44%) with supplemental data, 33% had myeloproliferative neoplasm, 20% underwent TIPS pre-LT, and 85% used anticoagulation post-LT. Post-LT anticoagulation was associated with improved PS (aHR:0.29,95%CI:0.16-0.54) and GS (aHR:0.48,95%CI:0.29-0.81). Hepatic artery thrombosis and portal vein thrombosis (PVT) occurred in 9% and 7%, while recurrent BCS was rare (3%).

CONCLUSIONS

LT for BCS results in excellent patient- and graft-survival. Older recipient or donor age and higher MELD are associated with poorer outcomes, while long-term anticoagulation improves both patient and graft outcomes.

European Society of Pediatric Radiology survey of perioperative imaging in pediatric liver transplantation: (1) pre-transplant evaluation

BACKGROUND

Liver transplantation is the state-of-the-art curative treatment in end-stage liver disease. Imaging is a key element for successful organ-transplantation to assist surgical planning. So far, only limited data regarding the best radiological approach to prepare children for liver transplantation is available.

OBJECTIVES

In an attempt to harmonize imaging surrounding pediatric liver transplantation, the European Society of Pediatric Radiology (ESPR) Abdominal Taskforce initiated a survey addressing the current status of imaging including the pre-, intra-, and postoperative phase. This paper reports the responses on preoperative imaging.

MATERIAL AND METHODS

An online survey, initiated in 2021, asked European centers performing pediatric liver transplantation 48 questions about their imaging approach. In total, 26 centers were contacted and 22 institutions from 11 countries returned the survey. From 2018 to 2020, the participating centers collectively conducted 1,524 transplantations, with a median of 20 transplantations per center per annum (range, 8-60).

RESULTS

Most sites (64%) consider ultrasound their preferred modality to define anatomy and to plan surgery in children before liver transplantation, and additional cross-sectional imaging is only used to answer specific questions (computed tomography [CT], 90.9%; magnetic resonance imaging [MRI], 54.5%). One-third of centers (31.8%) rely primarily on CT for pre-transplant evaluation. Imaging protocols differed substantially regarding applied CT scan ranges, number of contrast phases (range 1-4 phases), and applied MRI techniques.

CONCLUSION

Diagnostic imaging is generally used in the work-up of children before liver transplantation. Substantial differences were noted regarding choice of modalities and protocols. We have identified starting points for future optimization and harmonization of the imaging approach to multicenter studies.

European Society of Pediatric Radiology survey of perioperative imaging in pediatric liver transplantation: (2) intraoperative imaging

BACKGROUND

Liver transplantation is the state-of-the-art curative treatment for end-stage liver disease. Imaging is a key element in the detection of intraoperative and postoperative complications. So far, only limited data regarding the best radiological approach to monitor children during liver transplantation is available.

OBJECTIVE

To harmonize the imaging of pediatric liver transplantation, the European Society of Pediatric Radiology Abdominal Taskforce initiated a survey addressing the current status of imaging including the pre-, intra- and postoperative phase. This paper reports the responses related to intraoperative imaging.

MATERIALS AND METHODS

An online survey, initiated in 2021, asked European centers performing pediatric liver transplantation 48 questions about their imaging approach. In total, 26 centers were contacted, and 22 institutions from 11 countries returned the survey.

RESULTS

Intraoperative ultrasound (US) is used by all sites to assess the quality of the vascular anastomosis in order to ensure optimal perfusion of the liver transplant. Vessel depiction is commonly achieved using color Doppler (95.3%). Additional US-based techniques are employed by fewer centers (power angio mode, 28.6%; B-flow, 19%; contrast-enhanced US, 14.3%). Most centers prefer a collaborative approach, with surgeons responsible for probe handling, while radiologists operate the US machine (47.6%). Less commonly, the intraoperative US is performed by the surgeon alone (28.6%) or by the radiologist alone (23.8%). Timing of US, imaging frequency, and documentation practices vary among centers.

CONCLUSION

Intraoperative US is consistently utilized across all sites during pediatric liver transplantation. However, considerable variations were observed in terms of the US setup, technique preferences, timing of controls, and documentation practices. These differences provide valuable insights for future optimization and harmonization studies.

European Society of Pediatric Radiology survey of perioperative imaging in pediatric liver transplantation: (3) postoperative imaging

BACKGROUND

Liver transplantation is the state-of-the-art curative treatment for end-stage liver disease. Imaging is a key element in the detection of postoperative complications. So far, limited data is available regarding the best radiologic approach to monitor children after liver transplantation.

OBJECTIVE

To harmonize the imaging of pediatric liver transplantation, the European Society of Pediatric Radiology Abdominal Taskforce initiated a survey addressing the current status of imaging including the pre-, intra-, and postoperative phases. This paper reports the responses related to postoperative imaging.

MATERIALS AND METHODS

An online survey, initiated in 2021, asked European centers performing pediatric liver transplantation 48 questions about their imaging approach. In total, 26 centers were contacted, and 22 institutions from 11 countries returned the survey.

RESULTS

All sites commence ultrasound (US) monitoring within 24 h after liver transplantation. Monitoring frequency varies across sites, ranging from every 8 h to 72 h in early, and from daily to sporadic use in late postoperative phases. Predefined US protocols are used by 73% of sites. This commonly includes gray scale, color Doppler, and quantitative flow assessment. Alternative flow imaging techniques, contrast-enhanced US, and elastography are applied at 31.8%, 18.2%, and 63.6% of sites, respectively. Computed tomography is performed at 86.4% of sites when clarification is needed. Magnetic resonance imaging is used for selected cases at 36.4% of sites, mainly for assessment of biliary abnormalities or when blood tests are abnormal.

CONCLUSION

Diagnostic imaging is extensively used for postoperative surveillance of children after liver transplantation. While US is generally prioritized, substantial differences were noted in US protocol, timing, and monitoring frequency. The study highlights potential areas for future optimization and standardization of imaging, essential for conducting multicenter studies.

Cyclosporine vs. tacrolimus after liver transplantation for primary sclerosing cholangitis - a propensity score-matched intention-to-treat analysis

BACKGROUND & AIMS

There is controversy regarding the optimal calcineurin inhibitor type after liver transplant(ation) (LT) for primary sclerosing cholangitis (PSC). We compared tacrolimus with cyclosporine in a propensity score-matched intention-to-treat analysis based on registries representing nearly all LTs in Europe and the US.

METHODS

From the European Liver Transplant Registry (ELTR) and Scientific Registry of Transplant Recipients (SRTR), we included adult patients with PSC undergoing a primary LT between 2000-2020. Patients initially treated with cyclosporine were propensity score-matched 1:3 with those initially treated with tacrolimus. The primary outcomes were patient and graft survival rates.

RESULTS

The propensity score-matched sample comprised 399 cyclosporine-treated and 1,197 tacrolimus-treated patients with PSC. During a median follow-up of 7.4 years (IQR 2.3-12.8, 12,579.2 person-years), there were 480 deaths and 231 re-LTs. The initial tacrolimus treatment was superior to cyclosporine in terms of patient and graft survival, with 10-year patient survival estimates of 72.8% for tacrolimus and 65.2% for cyclosporine (p <0.001) and 10-year graft survival estimates of 62.4% and 53.8% (p <0.001), respectively. These findings were consistent in the subgroups according to age, sex, registry (ELTR vs. SRTR), time period of LT, MELD score, and diabetes status. The acute rejection rates were similar between groups. In the multivariable Cox regression analysis, tacrolimus (hazard ratio 0.72, p <0.001) and mycophenolate use (hazard ratio 0.82, p = 0.03) were associated with a reduced risk of graft loss or death, whereas steroid use was not significant.

CONCLUSIONS

Tacrolimus is associated with better patient and graft survival rates than cyclosporine and should be the standard calcineurin inhibitor used after LT for patients with PSC.

IMPACT AND IMPLICATIONS

The optimal calcineurin inhibitor to use after liver transplantation in patients with primary sclerosing cholangitis has yet to be firmly established. Since randomized trials with long follow-up are unlikely to be performed, multicontinental long-term registry data are essential in informing clinical practices. Our study supports the practice of using tacrolimus instead of cyclosporine in the initial immunosuppressive regimen after liver transplantation for patients with primary sclerosing cholangitis. The retrospective registry-based design is a limitation.

Minimally Invasive versus Open Distal Pancreatectomy in the 2020s: Recent Institutional Experience and a Narrative Review of Current Evidence

(1) Background: Distal pancreatectomy is a standard treatment for tumours of the pancreatic body and tail. Minimally invasive techniques for all types of pancreatic tumours (benign and malignant) are being established, while concerns regarding oncological safety, cost effectiveness and learning curves are being explored with prospective studies. This paper presents our unit's data in the context of the above concerns and provides a relevant narrative review of the current literature. (2) Methods: Data were collected retrospectively between 2014 and 2021 for all adult patients who underwent elective distal pancreatectomy in our tertiary care referral HPB Unit. Data on demographics, underlying pathology, perioperative variables and post-operative complications were collected and reported using descriptive statistics. On review of the Miami guidelines, four important but less validated areas regarding distal pancreatectomy are presented in light of the current evidence; these are recent randomised controlled trials, oncological safety, cost effectiveness and learning curves in minimally invasive distal pancreatectomy (MIDP). (3) Results: 207 patients underwent distal pancreatectomy in total from 2014-2021, with 114 and 93 patients undergoing open and minimally invasive techniques, respectively. 44 patients were operated on for PDAC in the open vs. 17 in the minimally invasive group. The operative time was 212 min for the open and 248 min for the minimally invasive group. The incidence of pancreatic fistula was higher in the minimally invasive group vs. the open group (16% vs. 4%). (4) Conclusions: Our unit's data conform with the published literature, including three randomised control trials. These published studies will not only pave the way for establishing minimally invasive techniques for suitable patients, but also define their limitations and indications. Future studies will inform us about the oncological safety, cost effectiveness, overall survival and learning curves regarding patients undergoing minimally invasive distal pancreatectomy.

Use of Near-Infrared Fluorescence Techniques in Minimally Invasive Surgery for Colorectal Liver Metastases

Colorectal liver metastases (CRLM) afflict a significant proportion of patients with colorectal cancer (CRC), ranging from 25% to 30% of patients throughout the course of the disease. In recent years, there has been a surge of interest in the application of near-infrared fluorescence (NIRF) imaging as an intraoperative imaging technique for liver surgery. The utilisation of NIRF-guided liver surgery, facilitated by the administration of fluorescent dye indocyanine green (ICG), has gained traction in numerous medical institutions worldwide. This innovative approach aims to enhance lesion differentiation and provide valuable guidance for surgical margins. The use of ICG, particularly in minimally invasive surgery, has the potential to improve lesion detection rates, increase the likelihood of achieving R0 resection, and enable anatomically guided resections. However, it is important to acknowledge the limitations of ICG, such as its low specificity. Consequently, there has been a growing demand for the development of tumour-specific fluorescent probes and the advancement of camera systems, which are expected to address these concerns and further refine the accuracy and reliability of intraoperative fluorescence imaging in liver surgery. While NIRF imaging has been extensively studied in patients with CRLM, it is worth noting that a significant proportion of published research has predominantly focused on the detection of hepatocellular carcinoma (HCC). In this study, we present a comprehensive literature review of the existing literature pertaining to intraoperative fluorescence imaging in minimally invasive surgery for CRLM. Moreover, our analysis places specific emphasis on the techniques employed in liver resection using ICG, with a focus on tumour detection in minimal invasive surgery (MIS). Additionally, we delve into recent developments in this field and offer insights into future perspectives for further advancements.

Surgical resection for large hepatocellular carcinoma and those beyond BCLC: systematic review with proposed management algorithm

BACKGROUND

Hepatocellular carcinoma (HCC) accounts for the sixth most common cancer and ranks third in mortality worldwide with inhomogeneity in terms of resection for advanced-stage disease.

METHODS

A systematic review of published literature using the PubMed, Medline, and Google Scholar databases from 1995 to 2020 was conducted to identify studies that reported outcomes of resection for solitary HCC > 10 cm, BCLC B/C, and multinodular HCC. Our aim was to assess overall survival for resection, identify poor prognostic factors, and to compare it to trans-arterial chemotherapy (TACE) where data was available.

RESULTS

Eighty-nine articles were included after a complete database search in the systematic review as per our predefined criteria. Analysis revealed a 5-year overall survival of 33.5% for resection of HCC > 10 cm, 41.7% for BCLC B, 23.3% for BCLC C, and 36.6% for multinodular HCC. Peri-operative mortality ranged from 0 to 6.9%. Studies comparing resection versus TACE for BCLC B/C had a survival of 40% versus 17%, respectively.

CONCLUSION

Our systematic review justifies hepatic resection wherever feasible for hepatocellular carcinomas > 10 cm, BCLC B, BCLC C, and multinodular tumors. In addition, we identified and proposed an algorithm with five poor prognostic criteria in this group of patients who may benefit from adjuvant TACE.

National Liver Allocation Policy-Consensus Document by the Liver Transplantation Society of India for a Nationally Uniform System of Allocation of Deceased Donor Liver Grafts

Background

Deceased donor liver transplantation (DDLT) is increasing in India and now constitutes nearly one-third of all liver transplantation procedures performed in the country. There is currently no uniform national system of allocation of deceased donor livers.

Methods

A national task force consisting of 19 clinicians involved in liver transplantation from across the country was constituted under the aegis of the Liver Transplantation Society of India to develop a consensus document addressing the above issues using a modified Delphi process of consensus development.

Results

The National Liver Allocation Policy consensus document includes 46 statements covering all aspects of DDLT, including minimum listing criteria, listing for acute liver failure, DDLT wait-list management, system of prioritisation based on clinical urgency for adults and children, guidelines for allocation of paediatric organs and allocation priorities for liver grafts recovered from public sector hospitals.

Conclusion

This document is the first step in the setting up of a nationally consistent policy of deceased donor liver allocation.

Validation of the Liver Transplant Risk Score in Europe

The Liver Transplant Risk Score (LTRS) is a simple clinical instrument developed to predict post liver transplant outcomes based on patient characteristics measured at the time of listing. The LTRS was developed using data of adult patients transplanted in the United States. In this study, we validated the performance of the LTRS in a cohort of patients transplanted in Europe.

Potential clinical utility of intraoperative fluid amylase measurement during pancreaticoduodenectomy

Backgrounds/Aims

Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is a source of major morbidity and mortality. Early diagnosis and treatment of POPF is mandatory to improve patient outcomes and clinical risk scores may be ombined with postoperative drain fluid amylase (DFA) values to stratify patients. The aim of this pilot study was to etermine if intraoperative fluid amylase (IFA) values correlate with DFA1 and POPF.

Methods

In patients undergoing PD from February to November 2020, intraoperative samples of intra-abdominal fluid adjacent to the pancreatic anastomosis were taken and sent for fluid amylase measurement prior to abdominal closure. Data regarding patient demographics, postoperative DFA values, complications, and mortality were prospectively collected.

Results

Data were obtained for 52 patients with a median alternative Fistula Risk Score (aFRS) of 9.9. Postoperative complications occurred in 20 (38.5%) patients (five Clavien grade ≥ 3). There were eight POPFs and two patients died (pneumonia/sepsis). There was a significant correlation between IFA and DFA1 (R² = 0.713; p < 0.001) and DFA3 (p < 0.001), and the median IFA was higher in patients with POPF than patients without (1,232.5 vs. 122; p = 0.0003). IFA > 260 U/L predicted POPF with sensitivity, specificity, positive and negative predictive values of 88.0%, 75.0%, 39.0%, and 97.0%, respectively. The incidence of POPF was 43.0% in high-risk (high aFRS/IFA) and 0% in lowrisk patients (low aFRS/IFA).

Conclusions

IFA correlated with POPF and may be a useful adjunct to clinical risk scores to stratify patients during PD. Larger, prospective studies are needed to determine whether IFA has clinical utility.

HPB P14 Para-aortic lymph node involvement should not be a contraindication to resection of pancreatic ductal adenocarcinoma

Background

Para-aortic lymph node (PALN) involvement is staged as metastatic disease but the literature is conflicting with no consensus on management. Aim: To investigate the prognostic significance of PALN metastases on the oncological outcomes after resection for PDAC.

Methods

A retrospective cohort study of prospectively maintained data of pancreatectomies for PDAC between 2011–2020. Statistical comparison between PALN+ and PALN- subgroups, using Kaplan-Meier and Cox regression analysis.

Results

81 cases had PALN sampling, 17 (21%) were positive. OS and DFS were comparable between PALN+ and PALN- patients (OS: 13.2 vs 18.8 months, p=0.161; DFS: 13 vs 16.4, p=0.179). No difference in OS or DFS was identified between PALN+ and PALN- patients when they received chemotherapy (neoadjuvant or adjuvant). On the contrary, when patients did not receive chemotherapy, PALN disease had substantially shorter OS (5.5 vs 14.2 months; p=0.015) and DFS (4.4 vs 9.8 months; p&lt;0.001). PALN involvement was not identified as an independent predictor for OS after multivariable analysis, while it was for DFS doubling the risk of recurrence.

Conclusions

PALN involvement does not affect OS when patients complete the multimodal treatment pathway and should not be considered as a contraindication to resection.

HPB P04 The DISSECT trial, ‘The effect of periaDventitIal SMA diSsECTion on margin status during pancreaticoduodenectomy for resectable pancreatic cancer’ Results of safety and feasibility pilot study

Background

Survival following pancreatic cancer resection remains poor despite advances in adjuvant and neoadjuvant therapy. The incidence of positive margin status (R1) is high and an R1 resection is associated with poorer survival. The most commonly positive margin is the SMA, accounting for between 47–77% of R1 resections. Periadventitial dissection of the SMA includes the lymphoneural tissue around the adventitia in addition to the ‘mesopancreas’ in the resection specimen and is used to varying extent across different centres. Theoretically this technique should reduce R1 resection rate, however, there is a lack of prospective evidence in the published literature.

Methods

The DISSECT trial is a single centre, randomised control trial. All patients with a resectable as per NCCN staging criteria head of pancreas tumour are randomised to either ‘periadventitial SMA dissection’ or ‘no periadventitial SMA dissection’ (1:1 block randomisation, sealed envelope system). A standardised technique for length and circumference of dissection is used and intra-operative photography with blinded assessment of dissection status ensures quality control. This safety and feasibility stage assesses recruitment, technique and complications and will be followed by a study powered to detect the primary outcome of reduction in positive SMA margin status. Primary outcomes to be assessed in the fully powered study will be the SMA margin status as detailed by the AJCC 8th edition. Secondary outcomes are status of other margins, length of stay, complications, overall and disease-free survival, complications, and adjuvant treatment details. These are assessed prospectively by an investigator blinded to the study arm.

Results

For the feasibility stage, the following criteria were set to proceed: recruitment of 20 patients in 6 months, at least 80% of recruited patients to undergo correct arm of randomisation, and an increase in complication rate of no more than 10%. Within the first 6 months, 32 patients were successfully recruited and randomised. 6 were excluded post-randomisation but before SMA approach (N=2 cancelled and not re-booked, N=2 abandoned after opening, N=2 converted to total pancreatectomy). N=3 were eligible but not recruited, (2 refused after approach and 1 was missed due to research team capacity). N=25 (96.2%) underwent their allocated study arm (confirmed by blinded photo assessment). For potentially procedure related complications (SMA bleed, post-operative haemorrhage, chyle leak, collection, and anastomotic leak) there was an overall rate of 38.5%, with no significant difference between the 2 arms (42.9% in No SMA dissection arm and 33.3% in the SMA dissection arm). There were no incidences of SMA branch bleed in the SMA dissection arm and a single post-operative haemorrhage in the SMA dissection arm that was due to a mesenteric venous bleed.

Conclusions

The DISSECT trial is a randomised controlled trial that aims to evaluate the use of a standardised technique of periadventitial SMA dissection to reduce the rate of R1 resection in early stages of pancreatic cancer. The feasibility and safety pilot is complete and demonstrates successful recruitment and randomisation, excellent adherence to randomisation arm and no operative concerns from the surgical team. The study will now proceed to full recruitment with complications and blinded photo reviews for quality control assessed contemporaneously. Primary and secondary outcomes will be recorded prospectively by a member of the research team blinded to randomisation arm.

HPB P49 Vein wall invasion is a more reliable predictor of oncological outcomes than vein related surgical margins after pancreaticoduodenectomy for early stages of pancreatic ductal adenocarcinoma

Background

Pancreaticoduodenectomy (PD) with vein resection is the only potentially curative option for patients with pancreatic ductal adenocarcinoma (PDAC) with venous involvement. The aim of our study was to assess the oncological prognostic significance of the different variables of venous involvement in patients undergoing PD for resectable and borderline resectable with venous only involvement (BR-V) PDAC.

Methods

Retrospective analysis of prospectively maintained PD database from 2011–2020 was performed. Standard descriptive statistical analysis; statistical comparisons with the use of the appropriate test; survival analysis with the Kaplan-Meier method and log rank test for overall survival (OS), disease-free survival (DFS) and local recurrence (LR); risk analysis for separate surgicalmargins with univariable and multivariable Cox proportional hazard model were used.

Results

One hundred and five of 372 patients (28%) required vein resection and vein wall involvement was identified in 37% of those. More vein resections were performed in female patients and as expected for BR-V disease.

OS, DFS and LR were significantly longer after R0 resection, irrespective of the need for a venous resection. Following analysis of separate surgical margins, the vein groove and the vein transection margins (the latter only applicable in patients that had a venous resection) were not identified as predictors of oncological outcomes. On the contrary, vein wall invasion was an independent predictor of OS (HR:1.947, CI: 1.228–3.089, p=0.005), DFS (HR: 2.169, CI: 1.306–3.602, p=0.003) and LR (HR: 2.365, CI: 1.089–5.133, p=0.030) after PD with venous resection.

Conclusions

Vein wall tumour invasion may be a more reliable predictor of oncological outcomes compared to traditionally reported parameters. Future studies should focus on possible pre-operative investigations that could identify these cases and management pathways that could yield survival benefit, such as the use of neoadjuvant treatments.

HPB P59 Is the lymph node ratio a relevant prognostic score neo-adjuvant chemotherapy for pancreatic cancer?

Background

Lymph node ratio (LNR) is a strong prognostic marker in pancreatic cancer (PDAC). In recent years, use of neoadjuvant chemotherapy (NAT) has increased, where it is associated with a higher rate of N0 resections, compared with a surgery first approach. The prognostic accuracy of the LNR after NAT has not been assessed.

Methods

Retrospective review of prospectively collected data from 2008–2020 of all patients undergoing pancreaticoduodenectomy (PD) for PDAC. Basic demographics, pathological and clinical outcomes were analysed using standard statistical tests. Cox regression and Kaplan-Meier analyses were performed.

Results

Retrospective review of prospectively collected data from 2008–2020 of all patients undergoing pancreaticoduodenectomy (PD) for PDAC. Basic demographics, pathological and clinical outcomes were analysed using standard statistical tests. Cox regression and Kaplan-Meier analyses were performed.

Conclusions

NAT reduces the predictive accuracy of the LNR in resected pancreatic cancer; alternative prognostic models will require development.

HPB P16 Impact of Frailty on Short-term Outcomes after Laparoscopic and Open Hepatectomy

Background

Although laparoscopic hepatectomy (LH) is associated with improved short-term outcomes compared to open hepatectomy (OH), it is unknown whether frail patients also benefit from LH. The aim of this study was to evaluate the impact of frailty on postoperative outcomes after LH and OH.

Methods

Consecutive patients who underwent LH and OH between January 2011 and December 2018 were identified from a prospective database. Frailty was assessed using the modified Frailty Index (mFI), with patients scoring mFI ≥ 1 deemed to be frail.

Results

Of 1826 patients, 34.7% (N=634) were frail and 18.6% (N=340) were elderly (≥ 75 years). Frail patients had significantly higher 90-day mortality (6.6% vs. 2.9%, p&lt;0.001) and postoperative complications (36.3% vs. 26.1%, p&lt;0.001) than those who were not frail, effects that were independent of patient age on multivariate analysis. For those undergoing minor resections, the benefits of LH vs. OH were similar for frail and non-frail patients. Length of hospital stay was 53% longer in OH (vs. LH) in frail patients, compared to 58% longer in the subgroup of non-frail patients.

Conclusions

Frailty is independently associated with inferior postoperative outcomes in patients undergoing hepatectomy. However, the benefits of laparoscopic (compared to open) hepatectomy are similar for frail and non-frail patients. Frailty should not be a contraindication to laparoscopic minor hepatectomy in carefully selected patients.

Clinical Spectrum of Children with Acute Hepatitis of Unknown Cause

BACKGROUND

Since January 2022, there has been an increase in reports of cases of acute hepatitis of unknown cause in children. Although cases have been reported across multiple continents, most have been reported in the United Kingdom. Investigations are ongoing to identify the causative agent or agents.

METHODS

We conducted a retrospective study involving children referred to a single pediatric liver-transplantation center in the United Kingdom between January 1 and April 11, 2022. These children were 10 years of age or younger and had hepatitis that met the case definition of the U.K. Health Security Agency for confirmed acute hepatitis that was not hepatitis A through E and did not have a metabolic, inherited or genetic, congenital, or mechanical cause, in the context of a serum aminotransferase level greater than 500 IU per liter. We reviewed medical records and documented demographic characteristics, clinical features, and results of liver biochemical, serologic, and molecular tests for hepatotropic and other viruses, as well as radiologic and clinical outcomes. The outcomes were classified as an improving condition, liver transplantation, or death.

RESULTS

A total of 44 children had hepatitis that met the confirmed case definition, and most were previously healthy. The median age was 4 years (range, 1 to 7). Common presenting features were jaundice (in 93% of the children), vomiting (in 54%), and diarrhea (in 32%). Among the 30 patients who underwent molecular testing for human adenovirus, 27 (90%) were positive. Fulminant liver failure developed in 6 patients (14%), all of whom received a liver transplant. None of the patients died. All the children, including the 6 who received liver transplants, were discharged home.

CONCLUSIONS

In this series involving 44 young children with acute hepatitis of uncertain cause, human adenovirus was isolated in most of the children, but its role in the pathogenesis of this illness has not been established.

Acute-on-chronic liver failure: A 20-year retrospective review of a tertiary paediatric liver centre

AIM

Acute-on-chronic liver failure (ACLF) is an acute deterioration of pre-existing chronic liver disease related to a precipitating event. We characterised paediatric ACLF at Birmingham Children's Hospital (BCH) utilising European Association of Liver Disease CLIF criteria, including prevalence, triggers and outcomes.

METHODS

All BCH patients from 2000 to 2020 with CLD who underwent initial liver transplant or died on the transplant waiting list or whilst too unwell to be listed were reviewed.

RESULTS

From 2000 to 2020, 24 (4%) children with ACLF were identified. Death occurred in 18 (75%). Transplant occurred in 9 (36%), 3 of which died. ACLF triggers were sepsis organism negative 11 (46%), sepsis organism positive 8 (33%) and GI bleed 5 (17%). Bilirubin at the time of transplant/death in those with ACLF who lived compared with those who died was 529 umol/L (381) versus 665 (210) (p=0.38), creatinine 138 umol/L (147) versus 67 (46) (p=0.41), PT 33 sec (14) versus (32 (15) (p = 0.72), Grade 3, 4 hepatic encephalopathy 1 (17%) versus 10 (56%) (p = 0.17), vasopressor use 1 (17%) versus 17 (94%) (p = 0.001) and ventilation 3 (50%) versus 17 (94%) (p = 0.035).

CONCLUSION

Acute-on-chronic liver failure whilst infrequent has high rates of mortality. The use of vasopressors and ventilation is more frequent in those who die from ACLF.

Can trainees safely perform pancreatoenteric anastomosis? A systematic review, meta-analysis, and risk-adjusted analysis of postoperative pancreatic fistula

BACKGROUND

The complexity of pancreaticoduodenectomy and fear of morbidity, particularly postoperative pancreatic fistula, can be a barrier to surgical trainees gaining operative experience. This meta-analysis sought to compare the postoperative pancreatic fistula rate after pancreatoenteric anastomosis by trainees or established surgeons.

METHODS

A systematic review of the literature was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, with differences in postoperative pancreatic fistula rates after pancreatoenteric anastomosis between trainee-led versus consultant/attending surgeons pooled using meta-analysis. Variation in rates of postoperative pancreatic fistula was further explored using risk-adjusted outcomes using published risk scores and cumulative sum control chart analysis in a retrospective cohort.

RESULTS

Across 14 cohorts included in the meta-analysis, trainees tended toward a lower but nonsignificant rate of all postoperative pancreatic fistula (odds ratio: 0.77, P = .45) and clinically relevant postoperative pancreatic fistula (odds ratio: 0.69, P = .37). However, there was evidence of case selection, with trainees being less likely to operate on patients with a pancreatic duct width <3 mm (odds ratio: 0.45, P = .05). Similarly, analysis of a retrospective cohort (N = 756 cases) found patients operated by trainees to have significantly lower predicted all postoperative pancreatic fistula (median: 20 vs 26%, P < .001) and clinically relevant postoperative pancreatic fistula (7 vs 9%, P = .020) rates than consultant/attending surgeons, based on preoperative risk scores. After adjusting for this on multivariable analysis, the risks of all postoperative pancreatic fistula (odds ratio: 1.18, P = .604) and clinically relevant postoperative pancreatic fistula (odds ratio: 0.85, P = .693) remained similar after pancreatoenteric anastomosis by trainees or consultant/attending surgeons.

CONCLUSION

Pancreatoenteric anastomosis, when performed by trainees, is associated with acceptable outcomes. There is evidence of case selection among patients undergoing surgery by trainees; hence, risk adjustment provides a critical tool for the objective evaluation of performance.

Long-Term Outcomes and Exploratory Analyses of the Randomized Phase III BILCAP Study

PURPOSE

The BILCAP study described a modest benefit for capecitabine as adjuvant therapy for curatively resected biliary tract cancer (BTC), and capecitabine has become the standard of care. We present the long-term data and novel exploratory subgroup analyses.

METHODS

This randomized, controlled, multicenter, phase III study recruited patients age 18 years or older with histologically confirmed cholangiocarcinoma or muscle-invasive gallbladder cancer after resection with curative intent and an Eastern Cooperative Oncology Group performance status of < 2. Patients were randomly assigned 1:1 to receive oral capecitabine (1,250 mg/m2 twice daily on days 1-14 of a 21-day cycle, for eight cycles) or observation. The primary outcome was overall survival (OS). This study is registered with EudraCT 2005-003318-13.

RESULTS

Between March 15, 2006, and December 4, 2014, 447 patients were enrolled; 223 patients with BTC resected with curative intent were randomly assigned to the capecitabine group and 224 to the observation group. At the data cutoff of January 21, 2021, the median follow-up for all patients was 106 months (95% CI, 98 to 108). In the intention-to-treat analysis, the median OS was 49.6 months (95% CI, 35.1 to 59.1) in the capecitabine group compared with 36.1 months (95% CI, 29.7 to 44.2) in the observation group (adjusted hazard ratio 0.84; 95% CI, 0.67 to 1.06). In a protocol-specified sensitivity analysis, adjusting for minimization factors, nodal status, grade, and sex, the OS hazard ratio was 0.74 (95% CI, 0.59 to 0.94). We further describe the prognostic impact of R status, grade, nodal status, and sex.

CONCLUSION

This long-term analysis supports the previous analysis, suggesting that capecitabine can improve OS in patients with resected BTC when used as adjuvant chemotherapy after surgery and should be considered as the standard of care.

The impact of advanced patient age in liver transplantation: a European Liver Transplant Registry propensity-score matching study

BACKGROUND

The futility of liver transplantation in elderly recipients remains under debate in the HCV eradication era.

METHODS

The aim was to assess the effect of older age on outcome after liver transplantation. We used the ELTR to study the relationship between recipient age and post-transplant outcome. Young and elderly recipients were compared using a PSM method.

RESULTS

A total of 10,172 cases were analysed. Recipient age >65 years was identified as an independent risk factor associated with reduced patient survival (HR:1.42 95%CI:1.23-1.65,p < 0.001). After PSM, 2124 patients were matched, and the same association was found between elderly recipients and patient survival and graft survival (p < 0.001). As hepatocellular carcinoma and alcoholic cirrhosis were independent prognostic factors for patient and graft survival a propensity score-matching was performed for each. Patient and graft survival were significantly worse (p < 0.05) in the alcoholic cirrhosis elderly group. However, patient and graft survival in the hepatocellular carcinoma cohort were similar (p > 0.05) between groups.

CONCLUSION

Liver transplantation is an acceptable and safe curative option for elderly transplant candidates, with worse long-term outcomes compare to young candidates. The underlying liver disease for liver transplantation has a significant impact on the selection of elderly patients.

Para-aortic lymph node involvement should not be a contraindication to resection of pancreatic ductal adenocarcinoma

BACKGROUND

Para-aortic lymph nodes (PALN) are found in the aortocaval groove and they are staged as metastatic disease if involved by pancreatic ductal adenocarcinoma (PDAC). The data in the literature is conflicting with some studies having associated PALN involvement with poor prognosis, while others not sharing the same results. PALN resection is not included in the standard lymphadenectomy during pancreatic resections as per the International Study Group for Pancreatic Surgery and there is no consensus on the management of these cases.

AIM

To investigate the prognostic significance of PALN metastases on the oncological outcomes after resection for PDAC.

METHODS

This is a retrospective cohort study of data retrieved from a prospectively maintained database on consecutive patients undergoing pancreatectomies for PDAC where PALN was sampled between 2011 and 2020. Statistical comparison of the data between PALN+ and PALN- subgroups, survival analysis with the Kaplan-Meier method and risk analysis with univariable and multivariable time to event Cox regression analysis were performed, specifically assessing oncological outcomes such as median overall survival (OS) and disease-free survival (DFS).

RESULTS

81 cases had PALN sampling and 17 (21%) were positive. Pathological N stage was significantly different between PALN+ and PALN- patients (P = 0.005), while no difference was observed in any of the other characteristics. Preoperative imaging diagnosed PALN positivity in one case. OS and DFS were comparable between PALN+ and PALN- patients with lymph node positive disease (OS: 13.2 mo vs 18.8 mo, P = 0.161; DFS: 13 mo vs 16.4 mo, P = 0.179). No difference in OS or DFS was identified between PALN positive and negative patients when they received chemotherapy either in the neoadjuvant or in the adjuvant setting (OS: 23.4 mo vs 20.6 mo, P = 0.192; DFS: 23.9 mo vs 20.5 mo, P = 0.718). On the contrary, when patients did not receive chemotherapy, PALN disease had substantially shorter OS (5.5 mo vs 14.2 mo; P = 0.015) and DFS (4.4 mo vs 9.8 mo; P < 0.001). PALN involvement was not identified as an independent predictor for OS after multivariable analysis, while it was for DFS doubling the risk of recurrence.

CONCLUSION

PALN involvement does not affect OS when patients complete the indicated treatment pathway for PDAC, surgery and chemotherapy, and should not be considered as a contraindication to resection.

Influence of middle hepatic vein resection during right or left hepatectomy on post hepatectomy outcomes

Backgrounds/Aims

Middle hepatic vein (MHV) is usually preserved as a part of the right or left hepatectomy in order preserve the venous outflow of remnant liver. The aim of this study was to evaluate if resection of MHV could influence post-resection outcomes of standard right or left hepatectomy.

Methods

Patients who underwent standard right or left hepatectomy between January 2015 and December 2019 were included. Anatomical remnant liver volumes were measured retrospectively using the Hermes workstation (Hermes Medical Solutions AB, Stockholm, Sweden). Uni- and multi-variate analyses were performed to assess the difference in outcomes of those with preservation of MHV and those without preservation.

Results

A total of 144 patients were included. Right hepatectomy was performed for 114 (79.2%) and left hepatectomy was performed for 30 (20.8%) patients. MHV was resected for 13 (9.0%) in addition to the standard right or left hepatectomy. Median remnant liver volume was significantly higher in the MHV resected group (p < 0.01). There was no significant difference in serum level of bilirubin, international normalized ratio, alanine aminotransferase, creatinine on postoperative day 1, 3, 5, or 10, ≥ grade IIIa complications (p = 0.44), or 90-day mortality (p = 0.41). On multivariable analysis, resection of the MHV did not influence the incidence of post hepatectomy liver failure (p = 0.52).

Conclusions

Resection of the MHV at standard right or left hepatectomy did not have a negative impact on postoperative outcomes of patients with adequate remnant liver volume.

Incidental gallbladder cancer diagnosis confers survival advantage irrespective of tumour stage and characteristics

BACKGROUND

Incidental gallbladder cancer (IGBC) represents 50%-60% of gallbladder cancer cases. Data are conflicting on the role of IGBC diagnosis in oncological outcomes. Some studies suggest that IGBC diagnosis does not affect outcomes, while others that overall survival (OS) is longer in these cases compared to non-incidental diagnosis (NIGBC). Furthermore, some studies reported early tumour stages and histopathologic characteristics as possible confounders, while others not.

AIM

To investigate the role of IGBC diagnosis on patients’ overall survival, especially after surgical treatment with curative intent.

METHODS

Retrospective analysis of all patient referrals with gallbladder cancer between 2008 and 2020 in a tertiary hepatobiliary centre. Statistical comparison of patient and tumour characteristics between IGBC and NIGBC subgroups was performed. Survival analysis for the whole cohort, surgical and non-surgical subgroups was done with the Kaplan-Meier method and the use of log rank test. Risk analysis was performed with univariable and multivariable Cox regression analysis.

RESULTS

The cohort included 261 patients with gallbladder cancer. 65% of cases had NIGBC and 35% had IGBC. A total of 90 patients received surgical treatment (66% of IGBC cases and 19% of NIGBC cases). NIGBC patients had more advanced T stage and required more extensive resections than IGBC ones. OS was longer in patients with IGBC in the whole cohort (29 vs 4 mo, P < 0.001), as well as in the non-surgical (14 vs 2 mo, P < 0.001) and surgical subgroups (29 vs 16.5 mo, P = 0.001). Disease free survival (DFS) after surgery was longer in patients with IGBC (21.5 mo vs 8.5 mo, P = 0.007). N stage and resection margin status were identified as independent predictors of OS and DFS. NIGBC diagnosis was identified as an independent predictor of OS.

CONCLUSION

IGBC diagnosis may confer a survival advantage independently of the pathological stage and tumour characteristics. Prospective studies are required to further investigate this, including detailed pathological analysis and molecular gene expression.

Late Bleeding Episodes Following Intestinal Transplantation: It Is Not Always Rejection or Infection

Ectopic varices have been reported in 5% of children presenting with variceal bleeding and are defined as portosystemic venous collaterals occurring anywhere in the abdomen except in the cardioesophageal region. The liver-intestinal transplant or isolated liver-intestinal transplant patient presenting several years post-transplant with ectopic variceal bleeding as a consequence of portal hypertension is a seldom reported complication. Etiologies such as rejection or infection are a more common source of bleeding, and only after excluding these can differentials such as portal hypertension secondary to a blocked portacaval shunt or native liver disease be considered.

External validation of postoperative pancreatic fistula prediction scores in pancreatoduodenectomy: a systematic review and meta-analysis

BACKGROUND

Multiple risk scores claim to predict the probability of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy. It is unclear which scores have undergone external validation and are the most accurate. The aim of this study was to identify risk scores for POPF, and assess the clinical validity of these scores.

METHODS

Areas under receiving operator characteristic curve (AUROCs) were extracted from studies that performed external validation of POPF risk scores. These were pooled for each risk score, using intercept-only random-effects meta-regression models.

RESULTS

Systematic review identified 34 risk scores, of which six had been subjected to external validation, and so included in the meta-analysis, (Tokyo (N=2 validation studies), Birmingham (N=5), FRS (N=19), a-FRS (N=12), m-FRS (N=3) and ua-FRS (N=3) scores). Overall predictive accuracies were similar for all six scores, with pooled AUROCs of 0.61, 0.70, 0.71, 0.70, 0.70 and 0.72, respectively. Considerably heterogeneity was observed, with I2 statistics ranging from 52.1-88.6%.

CONCLUSION

Most risk scores lack external validation; where this was performed, risk scores were found to have limited predictive accuracy. . Consensus is needed for which score to use in clinical practice. Due to the limited predictive accuracy, future studies to derive a more accurate risk score are warranted.

European Liver Transplant Registry: Donor and transplant surgery aspects of 16,641 liver transplantations in children

BACKGROUND AND AIMS

The European Liver Transplant Registry (ELTR) has collected data on liver transplant procedures performed in Europe since 1968.

APPROACH AND RESULTS

Over a 50-year period (1968-2017), clinical and laboratory data were collected from 133 transplant centers and analyzed retrospectively (16,641 liver transplants in 14,515 children). Data were analyzed according to three successive periods (A, before 2000; B, 2000-2009; and C, since 2010), studying donor and graft characteristics and graft outcome. The use of living donors steadily increased from A to C (A, n = 296 [7%]; B, n = 1131 [23%]; and C, n = 1985 [39%]; p = 0.0001). Overall, the 5-year graft survival rate has improved from 65% in group A to 75% in group B (p < 0.0001) and to 79% in group C (B versus C, p < 0.0001). Graft half-life was 31 years, overall; it was 41 years for children who survived the first year after transplant. The late annual graft loss rate in teenagers is higher than that in children aged <12 years and similar to that of young adults. No evidence for accelerated graft loss after age 18 years was found.

CONCLUSIONS

Pediatric liver transplantation has reached a high efficacy as a cure or treatment for severe liver disease in infants and children. Grafts that survived the first year had a half-life similar to standard human half-life. Transplantation before or after puberty may be the pivot-point for lower long-term outcome in children. Further studies are necessary to revisit some old concepts regarding transplant benefit (survival time) for small children, the role of recipient pathophysiology versus graft aging, and risk at transition to adult age.

Long-term outcome after living donor liver transplantation compared to donation after brain death in autoimmune liver diseases: Experience from the European Liver Transplant Registry

Knowledge of living donor liver transplantation (LDLT) for autoimmune liver diseases (AILDs) is scarce. This study analyzed survival in LDLT recipients registered in the European Liver Transplant Registry with autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis (PSC) and the non-autoimmune disorder alcohol-related cirrhosis. In total, 29 902 individuals enrolled between 1998 and 2017 were analyzed, including 1003 with LDLT. Survival from >90 days after LDLT for AILDs in adults was 85.5%, 74.2%, and 58.0% after 5, 10, and 15 years. Adjusted for recipient age, sex, and liver transplantation era, adult PSC patients receiving LDLT showed increased mortality compared to donation after brain death (DBD) (hazard ratio [HR] = 1.95, 95% confidence interval [CI] = 1.36-2.80, p < .001). Pediatric PSC patients showed also increased mortality >90 days after LDLT compared to DBD (HR = 3.00, 95% CI 1.04-8.70, p = .043). Multivariate analysis identified several risk factors for death in adult PSC patients receiving LDLT including a male donor (HR = 2.49, p = .025). Adult PSC patients with LDLT versus DBD conferred increased mortality from disease recurrence (subdistribution hazard ratio [subHR] = 5.36, p = .001) and biliary complications (subHR = 4.40, p = .006) in multivariate analysis. While long-term outcome following LDLT for AILD is generally favorable, PSC patients with LDLT compared to DBD might be at increased risk of death.

A coordinated national UK liver transplant program response, prioritising waitlist recipients with the highest need, provided excellent outcomes during the first wave of the COVID-19 pandemic

Healthcare provision has been severely affected by COVID-19, with specific challenges in organ transplantation. Here, we describe the coordinated response to, and outcomes during the first wave, across all UK liver transplant (LT) centres. Several policy changes affecting the liver transplant processes were agreed upon. These included donor age restrictions and changes to offering. A 'high-urgency' (HU) category was established, prioritising only those with UKELD >60, HCC reaching transplant criteria, and others likely to die within 90 days. Outcomes were compared with the same period in 2018 & 2019. The retrieval rate for deceased donor livers (71% vs 54%; p<0.0001) and conversion from offer to completed transplant (63% vs 48%; p<0.0001) was significantly higher. Paediatric LT activity was maintained; there was a significant reduction in adult (42%) and total (36%) LT. Almost all adult LT were super-urgent (n = 15) or HU (n = 133). We successfully prioritised those with highest illness severity with no reduction in 90-day patient (p = 0.89) or graft survival (p = 0.98). There was a small (5% compared with 3%; p = 0.0015) increase in deaths or removals from the waitlist, mainly amongst HU cohort. We successfully prioritised LT recipients in highest need, maintaining excellent outcomes, and waitlist mortality was only marginally increased. This article is protected by copyright. All rights reserved.

O-P06 Early postoperative differentiation between biochemical leak and clinically-relevant pancreatic fistula after pancreaticoduodenectomy: development of a predictive risk score

Background

Several risk scores are available which predict pancreatic fistula after pancreaticoduodenectomy (PD), but do not differentiate between biochemical leak (BL) and clinically relevant pancreatic fistula (CR-POPF). The aim of this study was to identify factors that differentiate between BL and CR-POPF in the early postoperative period.

Methods

Consecutive patients diagnosed with BL and CR-POPF after PD were identified from a prospectively maintained database (2009-2019). Data were collected for demographics, intraoperative and laboratory parameters on the first five postoperative days (PODs), including drain fluid amylase (DFA), C-reactive protein (CRP) and albumin. Independent predictors of CR-POPF were identified using a multivariable binary logistic regression model, which was subsequently converted to a risk score

Results

187 patients consisted of 99 BL and 88 CR-POPF. In those with CR-POPF, the leak became clinically relevant a median of 9 days after surgery; these patients had a significantly higher length of hospital stay than those with BL (median: 24 vs. 10 days, p &lt; 0.001). On multivariable analysis, male gender (p = 0.002), higher DFA (p &lt; 0.001) or CRP (p &lt; 0.001) on POD3, lower albumin (p = 0.028) on POD3 were all found to be independent predictors of CR-POPF. A risk score based on these factors returned an area under the ROC curve of 0.78.

Conclusions

In patients with a confirmed pancreatic fistula it may be possible to differentiate between BL and CR-POPF using early postoperative variables, particularly DFA, serum albumin and CRP. Early identification of CR-POPF may allow earlier intervention to improve clinical outcomes.

P-P34 Impact of an Enhanced Recovery After Surgery Protocol on Short-Term Outcomes in Elderly Patients Undergoing Pancreaticoduodenectomy

Background

In an effort to improve postoperative recovery and reduce complications, enhanced recovery after surgery (ERAS) pathways have been  introduced across a range of surgical disciplines. The demographics of patients being considered for PD have evolved over recent decades, with older patients undergoing increasingly more complex procedures. The feasibility and benefits of an ERAS protocol for elderly patients undergoing PD is debated, a recent study suggesting that age over 70 years is an independent risk factor for protocol failure . Existing studies on ERAS after PD in elderly patients are limited by small sample sizes and failure to include a pre-ERAS control.

Methods

830 consecutive patients who underwent PD between January 2009 and March 2019 were divided according to age: elderly (≥75 years) vs. non-elderly patients (&lt;75 years). Within each age group, cohort characteristics and outcomes were compared between patients treated pre- and post-ERAS (ERAS was systematically introduced in December 2012). Univariable and multivariable analysis were then performed, to assess whether ERAS was independently associated with length of hospital stay (LOS).

Results

Of the entire cohort, 577 of 830 patients (69.5%) were managed according to an ERAS protocol, and 170 patients (20.5%) were aged ≥ 75 years old. Patients treated post-ERAS were significantly more comorbid than those pre-ERAS, with a mean Charlson Comorbidity Index of 4.6 vs. 4.1 (p &lt; 0.001) and 6.0 vs. 5.7 (p = 0.039) for the non-elderly and elderly subgroups, respectively. There were significantly fewer medical complications in non-elderly patients treated post-ERAS compared to pre-ERAS (12.4% vs. 22.4%; p = 0.002), but not in elderly patients (23.6% vs. 14.0%; p = 0.203). On multivariable analysis, ERAS was independently associated with reduced LOS in both elderly (14.8% reduction, 95% CI: 0.7-27.0%, p = 0.041) and non-elderly patients (15.6% reduction, 95%CI: 9.2-21.6%, p &lt; 0.001), with the effect size being similar in each group.

Conclusions

ERAS protocol can be safely applied to patients undergoing pancreaticoduodenectomy irrespective of age. ERAS is associated with a significant reduction in postoperative LOS in elderly and non-elderly patients, despite higher comorbidity in the post-ERAS period.

P-P35 Textbook outcomes after pancreaticoduodenectomy in high risk patients: results from a high volume UK centre

Background

Textbook Outcome (TO) after pancreaticoduodenectomy (PD) is a quality metric that may be used to compare outcomes between centres, but the effect of casemix on TO is unknown. The aim of this study was to determine if TO after PD is affected by casemix.

Methods

TO was evaluated in a prospectively maintained database of 830 consecutive patients who underwent PD between 2009-2019 in a high volume centre. TO was defined as an absence of POPF, bile leak, haemorrhage, Clavien III+ complications, readmission and hospital mortality. Frequency of TO was compared between high and low risk cases. High risk was defined as any of the following: age ≥ 75 years, significant comorbidity (Charlson index ≥5), vascular resection or additional procedures. Multivariable analysis using binary logistic regression analysis was performed to assess factors associated with TO.

Results

Overall, 599/830 patients (72%) had TO after PD. There has been no change during the study period (2009-2013 v 2014-2018: 70% v 75%; p = 0.148). There was no difference in TO in elderly patients (p = 0.774), severe comorbidity (p = 0.483), vascular resection (p = 0.187) or additional procedures (p = 0.189). On multivariable analysis, cardiac disease (OR 0.47, 95%CI 0.28-0.81; p = 0.006), pancreatic adenocarcinoma (OR 1.55 95%CI 1.02-2.35; p = 0.039) and hard gland (OR 3.12, 95%CI 2.06-4.736; p &lt; 0.001) were independently associated with TO.

Conclusions

Acceptable Textbook Outcomes can be achieved in high risk patients and those undergoing complex surgery, when performed in high volume specialist centres with appropriate patient selection.

P-BN46 Risk Factors for Anastomotic Stricture after Hepaticojejunostomy for Bile Duct Injury – A Systematic Review and Meta-Analysis

Background

After major bile duct injury (BDI), hepaticojejunostomy (HJ) is usually required. This can lead to good long-term patency but anastomotic stricture unfortunately remains common cause of long-term morbidity after major BDI. Although risk factors for adverse outcomes of BDI repair are reasonably well understood, there is a need to assimilate high level evidence to establish risk factors specifically for development of anastomotic stricture after HJ for BDI.

Methods

This was a systematic review of studies reporting rate of anastomotic stricture after HJ for BDI was performed according to PRISMA guidelines. Where possible, meta-analyses were then performed to establish risk factors for anastomotic stricture after HJ for BDI.

Results

The meta-analyses performed included five factors with a total of 2,155 patients from 17 studies. An increased rate of anastomotic stricture after HJ for BDI was shown amongst patients with concomitant vascular injury (OR 4.96; 95%CI 1.92-12.86; p = 0.001), post-repair bile leak (OR: 8.03; 95%CI 2.04-31.71; p = 0.003) and repair by non-specialist surgeon (OR 11.29; 95%CI 5.21-24.47; p &lt; 0.0001). Level of injury according to Strasberg Grade did not significantly affect the rate of anastomotic stricture (OR: 0.97; 95%CI 0.45-2.10; p = 0.93). Due to heterogeneity of reporting it was not possible to perform meta-analysis for impact of timing of repair on anastomotic stricture rate.

Conclusions

Repair by a non-specialist surgeon was the only modifiable risk factor revealed by this meta-analysis and systematic review, which demonstrates the importance of broad awareness of these data. That said, knowledge of these risk factors permits evidence-based risk stratification of follow-up as well as better informed consent and understanding of prognosis for patients who have experienced major BDI and require HJ.

P-P49 Predicting Future Pathological and Operative Complexity in Pancreatoduodenectomy: 30 Years of Experience

Background

Patient selection for pancreatoduodenectomy (PD) is largely based upon local experience and established practice. This study sought to observe changes in complexity and patient cohort over time with the aim of predicting future cohort characteristic of patients undergoing PD.

Methods

All PDs at our institution between 1988 and 2020 were reviewed (n = 1,878) to observe changing trends in patient demographic, pathological diagnosis, operative factors and postoperative outcomes. Coefficients from regression models were reported as gradients per decade, to quantify the rate of change over time. The resulting models were then plotted to illustrate the trend across the study period, as well as forecasts for subsequent years.

Results

The annual volume (7 to 128) and proportion of pancreatic ductal adenocarcinoma (PDAC) (28 to 53%) increased at a linear rate. The proportion of associated vein resection (3 to 25%) and technical difficulty (type 2-4; 5 to 28%) increased in a nonlinear way, increasing more rapidly in later times. The average age (48 to 67) increased in a log linear trend. Length of stay reduced by 9.3%, whilst mortality reduced with an odds ratio of 0.69, per decade. Furthermore, When performance at our institution was compared to recently established benchmarks, it was shown that our institution regularly performed within these standards with few exceptions. By 2030 our predictions indicate that the average age will increase to 69, PDAC will comprise 62% of pathology, 40% will have an associated venous resection and 43% will be graded 2-4 in technical difficulty. Length of stay will have reduced to 9.6 days and mortality to 2%. 

Conclusions

Despite increasing complexity of surgery and patient age, length of stay and mortality after PD are reducing. Understanding changes over time permits an estimation of a future surgical cohort where complexity will increase. It is important that surgeons continue to push boundaries. Patient selection, based upon prior experience may inhibit progression and development of services.

Positional outflow obstruction as a cause of early refractory ascites post-pediatric living donor liver transplantation

Refractory ascites post-liver transplantation can be a challenging problem. Causes of refractory ascites include venous outflow anastomotic stenosis, vessel kinking by the regenerating liver, pre-existing graft disease, and positional outflow obstruction. We present a case report of a child presenting with high drain output and refractory ascites post-LDLT secondary to a positional kinking. Repeating the Doppler studies with patients both supine and sitting may be helpful.

Safety of intra-operative blood salvage during liver transplantation in patients with hepatocellular carcinoma, a propensity score-matched survival analysis

Intra-operative blood salvage (IBS) reduces the use of allogeneic blood transfusion. However, safety of IBS during liver transplantation (LT) for hepatocellular carcinoma (HCC) is questioned due to fear for dissemination of circulating malignant cells. This study aims to assess safety of IBS. HCC patients who underwent LT from January 2006 through December 2019 were included. Patients in whom IBS was used were propensity score matched (1:1) to control patients. Disease-free survival and time to HCC recurrence were assessed with Cox regression models and competing risk models. IBS was used in 192/378 HCC LT recipients, and 127 patients were propensity score matched. Cumulative disease-free survival at 12 and 60 months was 85% and 63% for the IBS group versus 90% and 68% for the no-IBS group. Use of IBS was not associated with impaired disease-free survival (HR 1.07, 95%CI: 0.65-1.76, P = 0.800) nor with increased HCC recurrence (Cause-specific cox model: HR 0.79, 95%CI: 0.36-1.73, P = 0.549, Fine and Gray model: HR: 0.79, 95%CI 0.40-1.57, P = 0.50). In conclusion, IBS during LT did not increase the risk for HCC recurrence. IBS is a safe procedure in HCC LT recipients to reduce the need for allogenic blood transfusion.

COVID-19 in liver transplant candidates: pretransplant and post-transplant outcomes - an ELITA/ELTR multicentre cohort study

OBJECTIVE

Explore the impact of COVID-19 on patients on the waiting list for liver transplantation (LT) and on their post-LT course.

DESIGN

Data from consecutive adult LT candidates with COVID-19 were collected across Europe in a dedicated registry and were analysed.

RESULTS

From 21 February to 20 November 2020, 136 adult cases with laboratory-confirmed SARS-CoV-2 infection from 33 centres in 11 European countries were collected, with 113 having COVID-19. Thirty-seven (37/113, 32.7%) patients died after a median of 18 (10-30) days, with respiratory failure being the major cause (33/37, 89.2%). The 60-day mortality risk did not significantly change between first (35.3%, 95% CI 23.9% to 50.0%) and second (26.0%, 95% CI 16.2% to 40.2%) waves. Multivariable Cox regression analysis showed Laboratory Model for End-stage Liver Disease (Lab-MELD) score of ≥15 (Model for End-stage Liver Disease (MELD) score 15-19, HR 5.46, 95% CI 1.81 to 16.50; MELD score≥20, HR 5.24, 95% CI 1.77 to 15.55) and dyspnoea on presentation (HR 3.89, 95% CI 2.02 to 7.51) being the two negative independent factors for mortality. Twenty-six patients underwent an LT after a median time of 78.5 (IQR 44-102) days, and 25 (96%) were alive after a median follow-up of 118 days (IQR 31-170).

CONCLUSIONS

Increased mortality in LT candidates with COVID-19 (32.7%), reaching 45% in those with decompensated cirrhosis (DC) and Lab-MELD score of ≥15, was observed, with no significant difference between first and second waves of the pandemic. Respiratory failure was the major cause of death. The dismal prognosis of patients with DC supports the adoption of strict preventative measures and the urgent testing of vaccination efficacy in this population. Prior SARS-CoV-2 symptomatic infection did not affect early post-transplant survival (96%).

Fifteen-Year Single-Center Experience of Biliary Complications in Liver Trauma Patients: Changes in the Management of Posttraumatic Bile Leak

INTRODUCTION

 Management of posttraumatic bile leak has evolved over time in our unit, from endoscopic retrograde cholangiopancreatography (ERCP) stenting to intraperitoneal drainage (IPD) alone as first-line treatment for intraperitoneal bile leak.

MATERIALS AND METHODS

 Retrospective review of liver trauma patients from 2002 to 2017. Demographics, time and mode of diagnosis of bile leak, management, and outcome were analyzed of the box plot.

RESULTS

 In 118 patients, there were 28 traumatic bile leaks. Eighteen were free intraperitoneal and 10 were localized bilomas. The median time of diagnosis was 6 days following injury. The modes of diagnosis were preemptive hepatobiliary scintigraphy (18), computed tomography (CT) or ultrasound (7), and laparotomy (3). Free intraperitoneal biliary leak management included 11 IPD alone, 3 IPD plus ERCP, 2 IPD plus transcystic biliary stent (TBS), 1 operative cholangiogram, and 1 no intervention. Median time of IPD duration was 7 days (4-95) in IPD alone versus 14 days (6-40) in IPD + ERCP/TBS (p = 0.3). Median inpatient length of stay was 13 days (8-44) in IPD alone versus 12 days (8-22) in IPD + ERCP/TBS (p = 0.4).

CONCLUSION

 Placement of IPD alone, as first-line treatment, is safe and effective in the management of intraperitoneal bile leaks, avoiding the costs and potential complications of ERCP.

Preoperative successful thrombectomy and thrombolysis of acute extensive splanchnic venous system and TIPSS thrombosis in a child with Budd-Chiari syndrome-Creating a window to enable living donor liver transplantation

Preoperative extensive PV thrombosis can pose a technical challenge during liver transplantation surgery. Several strategies adopted to mitigate this problem include creation of a superior mesenteric vein-PV jump graft, use of a polytetrafluoroethylene graft, renoportal anastomosis, or cavoportal hemitransposition. Extensive and diffuse thrombosis of the splanchnic venous system may even necessitate multivisceral transplantation. We describe the case of a pediatric patient with Budd-Chiari syndrome and decompensated cirrhosis, who developed extensive thrombosis of the porto-spleno-mesenteric venous system prior to liver transplantation. We used a combination technique of thrombus aspiration by a novel trans-TIPPS approach followed by thrombolysis. Complete preoperative resolution of the extensive thrombosis was achieved. This allowed the creation of a brief window to enable planned LDLT. In prudently selected patients, performing an early mechanical and chemical thrombolysis of an extensive acute splanchnic venous thrombosis can thus help expedite a planned LDLT.

What is the long-term outlook for young people following liver transplant? A single-centre retrospective analysis of physical and psychosocial outcomes

LT is a successful treatment for end-stage liver disease. The long-term outcome of patients transplanted in childhood has not previously been widely reported. This project assessed the long-term impact of transplantation in patients surviving >15 years. Retrospective data on growth, end-organ damage and psychosocial development were collected in young people transplanted from 1985 to 2000 in a single centre. Clinical notes were reviewed, and patients interviewed at clinic follow-up. 224 patients were transplanted between 1985 and 2000. 143 recipients (63.8%) survived >15 years with a median survival of 19.52 years. The majority were well, and only 10% had abnormal graft function (biochemical/synthetic), the main cause of which was chronic hepatitis (6%). Renal dysfunction and the necessity for renal transplant were identified in 32.8%, of whom 16.7% of patients had a cGFR <70 mL/min/1.73 m² and 6% of patients had either undergone or awaiting renal transplant. This cohort was healthier than the average age-matched UK population in terms of body mass index (9% obese), smoking and alcohol consumption. 92% of patients had completed or were in education (93/123 had completed education and 20/123 remained in school). 63.7% of patients had been transitioned into adult services, and 46.3% of these patients were employed. 67.5% were in a relationship, one patient was divorced, and 10.6% of patients had one or more children. 11 patients had symptoms that corresponded to a DSM IV diagnosis of depression. Four patients had anorexia nervosa. Developmental delay was identified in 9 out of 99 patients. The development of malignancy, including PTLD, occurred in 10/143 (7%) patients at a median time post-transplant of 2.76 years (range 0.76-9.06 years). Epstein-Barr infection was implicated in 75% of these malignancies. We conclude the long-term outcome of LT in childhood is good with 63.8% surviving into adulthood and over 60% transferring into adult services. Graft dysfunction and end organ damage are minimal. Our cohort is healthier than the general population, and the majority have completed education, sought employment and formed relationships with peers, contributing well to society.

Organ Restoration With Normothermic Machine Perfusion and Immune Reaction

Liver transplantation is the only recognized effective treatment for end-stage liver disease. However, organ shortages have become the main challenge for patients and physicians within the transplant community. Waiting list mortality remains an issue with around 10% of patients dying whilst waiting for an available organ. The post-transplantation period is also associated with an adverse complication rate for these specific cohorts of high-risk patients, particularly regarding patient and graft survival. Ischaemia reperfusion injury (IRI) has been highlighted as the mechanism of injury that increases parenchymal damage, which eventually lead to significant graft dysfunction and other poor outcome indicators. The consequences of IRI in clinical practice such as reperfusion syndrome, primary non-function of graft, allograft dysfunction, ischaemic biliary damage and early biliary complications can be life-threatening. IRI dictates the development of a significant inflammatory response that drives the pathway to eventual cell death. The main mechanisms of IRI are mitochondrial damage due to low oxygen tension within the hepatic micro-environment and severe adenosine triphosphate (ATP) depletion during the ischaemic period. After the restoration of normal blood flow, this damage is further enhanced by reoxygenation as the mitochondria respond to reperfusion by releasing reactive oxygen species (ROS), which in turn activate Kupffer cells within the hepatic micro-environment, leading to a pro-inflammatory response and eventual parenchymal cell apoptosis and associated tissue degradation. Machine perfusion (MP) is one emergent strategy considered to be one of the most important advances in organ preservation, restoration and transplantation. Indeed, MP has the potential to rescue frequently discarded organs and has been shown to limit the extent of IRI, leading to suppression of the deleterious pro-inflammatory response. This immunomodulation reduces the prevalence of allograft rejection, the use of immunosuppression therapy and minimizes post-transplant complications. This review aims to update the current knowledge of MP with a focus on normothermic machine liver perfusion (NMLP) and its potential role in immune response pathways.