Recommendations on intervention for hepatobiliary oncological surgery during the COVID-19 pandemic

The SARS-CoV-2 (COVID-19) pandemic requires an analysis in the field of oncological surgery, both on the risk of infection, with very relevant clinical consequences, and on the need to generate plans to minimize the impact on possible restrictions on health resources.

The AEC is making a proposal for the management of patients with hepatopancreatobiliary (HPB) malignancies in the different pandemic scenarios in order to offer the maximum benefit to patients, minimising the risks of COVID-19 infection, and optimising the healthcare resources available at any time. This requires the coordination of the different treatment options between the departments involved in the management of these patients: medical oncology, radiotherapy oncology, surgery, anaesthesia, radiology, endoscopy department and intensive care.

The goal is offer effective treatments, adapted to the available resources, without compromising patients and healthcare professionals’ safety.

Recommendations on intervention for hepatobiliary oncological surgery during the COVID-19 pandemic

The SARS-CoV-2 (COVID-19) pandemic requires an analysis in the field of oncological surgery, both on the risk of infection, with very relevant clinical consequences, and on the need to generate plans to minimize the impact on possible restrictions on health resources. The AEC is making a proposal for the management of patients with hepatopancreatobiliary (HPB) malignancies in the different pandemic scenarios in order to offer the maximum benefit to patients, minimising the risks of COVID-19 infection, and optimising the healthcare resources available at any time. This requires the coordination of the different treatment options between the departments involved in the management of these patients: medical oncology, radiotherapy oncology, surgery, anaesthesia, radiology, endoscopy department and intensive care. The goal is offer effective treatments, adapted to the available resources, without compromising patients and healthcare professionals safety.

Mortality after Transplantation for Hepatocellular Carcinoma: A Study from the European Liver Transplant Registry

BACKGROUND AND AIMS

Prognosis after liver transplantation differs between hepatocellular carcinoma (HCC) arising in cirrhotic and non-cirrhotic livers and aetiology is poorly understood. The aim was to investigate differences in mortality after liver transplantation between these patients.

METHODS

We included patients from the European Liver Transplant Registry transplanted due to HCC from 1990 to November 2016 and compared cirrhotic and non-cirrhotic patients using propensity score (PS) calibration of Cox regression estimates to adjust for unmeasured confounding.

RESULTS

We included 22,787 patients, of whom 96.5% had cirrhosis. In the unadjusted analysis, non-cirrhotic patients had an increased risk of overall mortality with a hazard ratio (HR) of 1.37 (95% confidence interval [CI] 1.23-1.52). However, the HR approached unity with increasing adjustment and was 1.11 (95% CI 0.99-1.25) when adjusted for unmeasured confounding. Unadjusted, non-cirrhotic patients had an increased risk of HCC-specific mortality (HR 2.62, 95% CI 2.21-3.12). After adjustment for unmeasured confounding, the risk remained significantly increased (HR 1.62, 95% CI 1.31-2.00).

CONCLUSIONS

Using PS calibration, we showed that HCC in non-cirrhotic liver has similar overall mortality, but higher HCC-specific mortality. This may be a result of a more aggressive cancer form in the non-cirrhotic liver as higher mortality could not be explained by tumour characteristics or other prognostic variables.

Intraoperative Portal Vein Flow > 123 mL/min Per 100 g Predicts a Better Survival of Patients After Liver Transplantation

OBJECTIVE

To assess the importance of intraoperative portal vein flow measurement during liver transplantation in relation to postoperative complications and graft and patient survival.

MATERIALS AND METHODS

Retrospective review including 291 patients who had all the information and covering a period of 10 years (2007-2017). Using a receiver operating characteristic curve, a cut-off point that would have the greatest impact on the probability of being alive at 5 years was established. In relation to this value, 2 groups were formed (low and high flow) and demographic variables, intraoperative variables, postoperative complications, and graft and patient survival were compared.

RESULTS

A portal flow of 123 mL/min per100 g of liver tissue was established (area under the curve = 0.58), obtaining a low-flow (n = 129) and a high-flow group (n = 162). The 2 groups were similar in their preoperative characteristics, except for a higher proportion of preoperative ascites, a higher Model for End-Stage Liver Disease score and a lower weight of donors in the high-flow group. The arterial and portal flows were significantly higher in the high-flow group. In the postoperative period, the high-flow group presented a higher rate of ascites. The 5-year survival rate of patients was significantly higher in the high-flow group (76% vs 84%, P = .03).

CONCLUSIONS

Patients undergoing liver transplantation with an intraoperative portal vein flow measurement >123 mL/min per 100 g present a greater 5-year survival rate.

Locoregional treatments before liver transplantation for hepatocellular carcinoma: a study from the European Liver Transplant Registry

Locoregional treatment while on the waiting list for liver transplantation (Ltx) for hepatocellular carcinoma (HCC) has been shown to improve survival. However, the effect of treatment type has not been investigated. We investigate the effect of locoregional treatment type on survival after Ltx for HCC. We investigated patients registered in the European Liver Transplant Registry database using multivariate Cox regression survival analysis. Information on locoregional therapy was registered for 4978 of 23 124 patients and was associated with improved overall survival [hazard ratio (HR) 0.84 (0.73-0.96)] and HCC-specific survival [HR 0.76 (0.59-0.98)]. Radiofrequency ablation (RFA) was the one monotherapy associated with improved overall survival [HR 0.51 (0.40-0.65)]. In addition, the combination of RFA and transarterial chemoembolization also improved survival [HR 0.74 (0.55-0.99)]. Adjusting for factors related to prognosis, disease severity, and tumor aggressiveness, RFA was highly beneficial for overall and HCC-specific survival. The effect may represent a selection of patients with favorable tumor biology; however, the treatment may be effective per se by halting tumor progression. Clinicaltrials.gov number: NCT02995096.

Shipping impact on liver graft: results of liver transplantation program in Andalusia

Liver transplantation for the treatment of patients with advanced liver disease is organized according to a waiting list taking into account different criteria. The agreed distribution model in Andalusia assumes that sometimes an organ is extracted in a different province to that where the implantation is to be performed (shipping), which, therefore, increases the graft ischemic time. The aim of the present study was to determine whether transportation of the organ and being harvested by a team other than the implantation team have a negative effect on final patient survival.

Analysis of the recurrence of hepatitis C virus after liver transplantation: results of the Andalusian liver registry

OBJECTIVE

This study analyzed the factors related to recurrence of hepatitis C virus (HCV) among orthotopic liver transplantation (OLT) patients.

PATIENTS AND METHODS

We undertook a multicenter, prospective, observational study of OLT patients transplanted due to HCV at four Andalusian transplantation centers from 2005 to 2007. Patients were excluded if their survival was less than 1 month. The analysis included 110 pre-, peri-, and posttransplant variables that could affect HCV recurrence. We also examined the influence of cardiovascular risk factors and immunosuppression on HCV.

RESULTS

Among 121 HCV patients, 83 (69%) experienced a histologically significant recurrence of HCV, including 13 (16%) who died compared with 5 of 38 (13%) who did not show a severe recurrence of HCV (P = .3). The mean follow-up was 44 months (range, 4 to 64 months). The mean time to appearance of the relapse was 9 months (range, 1 to 40 months) with no differences according to the type of immunosuppression. Of all study variables, donor age (> 52 years) showed a trend for greater recurrence (P = .1). The use of powerful immunosuppression (three or more drugs), either as induction or as sustained therapy, during the first posttransplantation year was significantly associated with a greater relapse rate (P < .01), albeit with no significant difference according to the type of calcineurin inhibitor. Mycophenolate mofetil was not associated with a greater posttransplantation viral load or earlier relapse, although its use in multiple immunosuppression schedules was associated with a greater relapse rate (P < .01). Survival of patients with recurrent HCV was reduced, although not significantly. Multivariate analysis showed a 4.4 times greater risk for developing de novo diabetes mellitus (DM) among patients with a severe relapse of HCV.

CONCLUSIONS

There was an important trend toward a greater recurrence rate of HCV among patients who received powerful immunosuppression protocols, particularly during the first 12 months. Special attention should be given to the risk for de novo DM among HCV-positive patients.

Have we changed the liver retransplantation survival?

INTRODUCTION

Orthotropic liver retransplantation (RT) is the therapeutic option for the failure of an allograft. Patient and graft survival rates after RT are inferior to primary liver transplantation (OLT). Because of the limited number of donors, it is essential that we optimize their use. We reviewed 68 consecutive retransplantations to evaluate their results.

MATERIALS AND METHODS

Using registry data from our Liver Transplantation Unit, we performed a retrospective cohort study of adult RT between 1991 and 2010. Patients were divided into 2 groups (urgent vs elective RT) to compare the utility of RT. We also analyzed data collected at the time of RT, including age, gender, indications for primary OLT and RT (hepatitis C virus [HCV]+ and HCV-). At various stages (1991-2000, 2001-2006, and 2007-2010), we calculated probability survival curves according to the Kaplan-Meier method with comparisons using the log-rank test.

RESULTS

Among 771 adult liver transplantations, 68 (8.8%) underwent late secondary OLT. 21 (31%) cases were urgent and 47 elective RT (69%). Vascular complications was the most common cause for urgent RT, and chronic rejection, for elective RT. Differences were also detected in the overall survival of RT patients; mortality was significantly lower among the urgent procedures (15% vs 47.8%). Significantly differences were also detected in overall survival for RT patients between 2007 and 2010 (81.7% with urgent RT and 76.5% with elective situations).

CONCLUSION

These data confirmed the utility of RT in elective and emergency situations. Overall survival of elective RT patients has improved in recent years. Liver RT requires a multidisciplinary team to decide the inclusion and prioritization of elective RT cases on the OLT waiting list.

Rescue immunosuppression with mammalian target of rapamycin inhibitor drugs in liver transplantation

BACKGROUND

Mammalian target of rapamycin (mTOR) inhibitors behave as potent immunosuppressants, which have the advantages, with respect to calcineurin inhibitors (CNI; cyclosporine or tacrolimus), of no nephrotoxicity but inhibition of cell proliferation. They are particularly suitable for patients with renal insufficiency or neoplasias.

MATERIALS AND METHODS

Twenty-eight liver transplant patients were immunosuppressed with everolimus or sirolimus as rescue therapy after CNI treatment: 8 hepatocellular carcinomas; 7 de novo malignancies; 6 renal insufficiencies; 3 chronic rejections; 3 acute rejection episodes; and 1 epilepsy.

RESULTS

There were 0% tumor recurrences, 50% improvements in 33% no change, and 17% worsening of renal function among cases of renal insufficiency; 0% improvement in cases of chronic rejection, and 33% improvement in acute rejection episodes. There was a 7% incidence of acute rejection episodes, but no kidney failure, gastrointestinal intolerance, hydrocarbon intolerance, hypertension, or arterial or venous thrombosis. Diarrhea occurred in 7%; hypercholesterolemi in 46% hypertriglyceridemia in 50% thrombocytopenia in 14%, leukopenia in 14%, and anemia in 39%. The 12% intercurrent infection rate included oral thrush in 11%. Lower limb edema occurred in 21%; 1 case displayed facial edema and 1, alopecia.

CONCLUSIONS

mTOR inhibitors were safe immunosuppressive drugs whose side effects were controlled and easily managed. They have advantages with respect to CNI due to their slight effects on kidney function and lack of promotion of diabetes mellitus. Although their long-term effectiveness for control of neoplastic diseases is yet to be seen, they can be used safely in these patients with a low incidence of rejection. Their effectiveness to control steroid-resistant acute rejection episodes or renal insufficiency seems significant, but they are of doubtful benefit for chronic rejection.

Indications for and survival after liver retransplantation

INTRODUCTION

Orthotopic liver retransplantation (re-OLT) is the therapeutic option for hepatic graft failures. Survival after re-OLT is poorer than after primary OLT. Given that there is an organ shortage, it is essential that we optimize our use of this scarce resource. We evaluated the results of re-OLT among 58 consecutive Re-OLT.

MATERIALS AND METHODS

Using registry data from our Liver Transplantation Unit, we performed a retrospective cohort study of adult urgent versus elective re-OLT between 1991 and 2008. We recorded the indications for the initial OLT, and the intervals from OLT to re-OLT as well as age and gender. Using the Rosen model to stratify patients into low-intermediate-, and high-risk groups we calculated survivals.

RESULTS

Among 661 adult liver transplantations, 56 patients (8.4%) underwent late re-OLT at a median of 654.4 days post-OLT. There were 17 (29%) urgent re-OLT and 41 elective cases (71%). Vascular complications were the most common cause of urgent re-OLT (64%); elective re-OLT was primarily due to chronic rejection (56.1%). Overall survival for retransplanted patients was significantly lower among urgent procedures (82.4% vs 48.8%), as well as for overall survival after re-OLT for patients with hepatitis C virus (HCV) versus other etiologies.

CONCLUSION

These data confirmed the utility of retransplantation in elective and emergency situations. Liver re-transplantation has a high morbidity and mortality. It requires multidisciplinary experience to decide inclusion and prioritization criteria for re-OLT, especially among patients with HCV.