Split liver transplantation with extended right grafts on adult recipients: A propensity score matching analysis

INTRODUCTION

Split liver transplantation (SLT) emerged due to its potential to contribute to the organ pool and reduce organ shortage. However, SLT is technically challenging and has been associated with higher rates of postoperative complications leading to concerns about graft and patient survival. Moreover, there are few studies on matched-pair adult recipients of SLT and whole-liver transplant (WLT), with conflicting results.

METHODS

This retrospective study analyze outcomes among adults who underwent SLT at our institution from 2010 to 2019. A 1:1 propensity score matching analysis was performed based on important donor and recipient variables. Baseline characteristics and postoperative outcomes were analyzed and compared between groups. Actuarial graft and patient survival were analyzed by KM curves.

RESULTS

Out of 592 adults receiving a LT in our institution, 21 SLT adult recipients were identified and matched with 21 adults undergoing WLT. As expected donor age was significantly lower in SLT recipients (16 (15-22) vs. 32 (17-47), P = .012). Additional donor characteristics, including anthropometrics, and ischemic times were similar between groups. Baseline recipient characteristics and postoperative outcomes, including length of stay, vascular complications, biliary complications, and re-transplantation were comparable between SLT and WLT recipients. Graft (95/95/95 vs. 100/94/94, P = .98) and patient (100/100/100 vs. 100/94/94, P = .30) survival at 1-, 3-, 5-years, were similar between the SLT- and WLT group, respectively.

CONCLUSION

Split liver transplantation has the potential to increase the availability of organs for adult recipients without compromising individual outcomes.

Donor Morbidity Is Equivalent Between Right and Left Hepatectomy for Living Liver Donation: A Meta-Analysis

Maximizing liver graft volume benefits the living donor liver recipient. Whether maximizing graft volume negatively impacts living donor recovery and outcomes remains controversial. Patient randomization between right and left hepatectomy has not been possible due to anatomic constraints; however, a number of published, nonrandomized observational studies summarize donor outcomes between 2 anatomic living donor hepatectomies. This meta-analysis compares donor-specific outcomes after right versus left living donor hepatectomy. Systematic searches were performed via PubMed, Cochrane, ResearchGate, and Google Scholar databases to identify relevant studies between January 2005 and November 2019. The primary outcomes compared overall morbidity and incidence of severe complications (Clavien-Dindo >III) between right and left hepatectomy in donors after liver donation. Random effects meta-analysis was performed to derive summary risk estimates of outcomes. A total of 33 studies (3 prospective and 30 retrospective cohort) were used to identify 7649 pooled patients (5993 right hepatectomy and 1027 left hepatectomy). Proportion of donors who developed postoperative complications did not significantly differ after right hepatectomy (0.33; 95% confidence interval [CI], 0.27-0.40) and left hepatectomy (0.23; 95% CI, 0.17-0.29; P = 0.19). The overall risk ratio (RR) did not differ between right and left hepatectomy (RR, 1.16; 95% CI, 0.83-1.63; P = 0.36). The relative risk for a donor to develop severe complications showed no differences by hepatectomy side (Incidence rate ratio, 0.97; 95% CI, 0.67-1.40; P = 0.86). There is no evidence that the overall morbidity differs between right and left lobe donors. Publication bias reflects institutional and surgeon variation. A prospective, standardized, multi-institutional study would help quantify the burden of donor complications after liver donation.

The natural history of non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease has a variable prognosis which is predictable to an extent based on the presence or absence of histological liver injury. Past studies have determined a number of clinical and laboratory parameters which predict greater severity on the initial biopsy, although all of these measures have limitations and biopsy remains the gold standard at this time. For patients with early stage non-alcoholic steatohepatitis (NASH), about one third will progress to stage 3 or 4 (cirrhosis) over 5-10 years. Thus, early-stage NASH constitutes one of the groups most likely to benefit from treatments now undergoing investigation. Among those who progress to NASH cirrhosis, about 25% will develop major complications of portal hypertension within 3 years. In contrast, non-NASH fatty liver tends to be stable over time, although there appears to be an increased cancer risk in all forms of fatty liver, albeit greater in NASH compared to non-NASH fatty liver. Interestingly, the cause of death among patients with NASH is more often due to cardiovascular disease or non-liver malignancy than cirrhosis. However, the accelerated risk of cirrhosis in this group compared to cardiovascular disease suggests that this picture is likely to change in the foreseeable future. Meanwhile, the relationship between these comorbidities will increasingly lead to patients with both coronary disease or malignancy and NASH-related cirrhosis presenting clinicians with a very challenging set of problems in coming years.

Accelerated treatment using intensity-modulated radiation therapy plus concurrent capecitabine for unresectable hepatocellular carcinoma

BACKGROUND

: Patients with unresectable hepatocellular carcinoma (HCC) have limited treatment options. In this study, the authors investigated the feasibility, toxicity, and efficacy associated with intensity-modulated radiation therapy (IMRT) and concurrent, chronomodulated capecitabine in the treatment of unresectable HCC.

METHODS

: Twenty patients underwent treatment planning for HCC confined to the liver with helical tomotherapy-based IMRT. Fifty-five percent of patients had Child-Pugh Class A disease, and 45% of patients had Class B disease. Ninety-five percent of patients were prescribed 50 gray (Gy) of radiotherapy to the planning target volume delivered in 20 fractions with concurrent, chronomodulated capecitabine. Transcatheter arterial chemoembolization preceded radiotherapy in 11 patients, and 9 patients received IMRT alone because of portal vein thrombosis, esophageal varices, or tumor size.

RESULTS

: The mean greatest tumor dimension was 9 cm (range, 1.3-17.4 cm), the mean dose to normal liver was 22.6 Gy (range, 10-29.2 Gy), and the average volume of liver that received >30 Gy (V30) was 27.2% (range, 12%-43%). Eighteen patients (90%) completed the prescribed treatment of 50 Gy. There was no increase from baseline in acute or late toxicity greater than 2 grades. Partial response or disease stability was achieved at 3 months to 6 months after treatment in 15 of 16 patients (94%). The median survival (+/-standard deviation) for patients who had Child-Pugh Class A and B disease was 22.5 +/- 5.1 months and 8 +/- 3.3 months, respectively.

CONCLUSIONS

: In this initial experience with accelerated IMRT plus capecitabine for patients who had large HCC lesions, the results demonstrated acceptable toxicity with promising local control. The relatively low acute and late toxicity observed with this program suggested that dose intensification can be incorporated into the treatment regimen if needed. Cancer 2009. (c) 2009 American Cancer Society.

Endoscopic cyanoacrylate versus transjugular intrahepatic portosystemic shunt for gastric variceal bleeding: a single-center U.S. analysis

BACKGROUND AND OBJECTIVES

Gastric variceal hemorrhage treatment remains a difficult issue for clinicians. There is controversy regarding whether first-line treatment should be endoscopic therapy with cyanoacrylate glue or placement of a transjugular intrahepatic portosystemic shunt (TIPS). We compared these methods on the basis of rebleeding, survival, and complications. DESIGN, SETTING, PATIENTS, AND INTERVENTIONS: This was a retrospective cohort analysis of cirrhotic patients with gastric variceal hemorrhage treated with endoscopic cyanoacrylate therapy or TIPS placement at a single U.S. center from 1997 to 2007. The groups were compared for rebleeding at 72 hours, 3 months, and 1 year; survival rates at 3 months and 1 year; and acute and extended complications and morbidity.

MAIN OUTCOME MEASUREMENTS AND RESULTS

A total of 105 patients were included. There were no significant pretreatment differences between the 2 groups in age, sex, MELD (Model for End-Stage Liver Disease) score at the time of admission, or cause of liver disease. There were no significant differences in rebleeding at 72 hours, 3 months, and 1 year; survival at 3 months and 1 year; and aggregate long-term survival or acute complications. However, the TIPS group had a higher rate of long-term morbidity requiring hospitalization (41% with a TIPS and 1.6% in the cyanoacrylate arm, P < .0001).

LIMITATIONS

Retrospective and uncontrolled samples.

CONCLUSION

In patients with similar characteristics, cyanoacrylate therapy performed as well as a TIPS in controlling and preventing gastric variceal hemorrhage with no significant differences in survival. Patients receiving cyanoacrylate therapy experienced significantly less long-term morbidity related to therapy than patients who received a TIPS. Cyanoacrylate therapy appears to be safe and effective and compares favorably with TIPS therapy.