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Retransplantation for graft failure more than 5 years after primary liver transplant
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Electronic Poster Abstracts
Methods: Demographic and surgical data of patients transplanted between 1996 and February 2015 were analyzed. A classification was made: Type I: end-to-end hepatic anastomosis; type II: direct end-to-side aortic anastomosis; type III: iliac by-pass to the aorta; type IV: end-to-end anastomosis in living donor graft (LDG); type V: multiple vascular anastomoses; type VI: use of vascular prosthesis. Rate of HAT was determined for each type of anastomosis and Odds Ratio (two-tailed Fisher exact test) was analyzed. Results: 207 PLT were performed in 171 patients, 90 males, median age 5.5 years. Type of anastomosis; Type I 80 (38.6%), type II 18 (8.7%), type III 18 (8.7%), type IV 46 (22.2%), type V 45 (21.7%) Type VI 0. There were 21 HAT (10.1%), 13 (61.9%) were successfully revascularized, 8 required retransplantation. Rate of HAT was 5 for type I (6.3%) p = 0.37, 5 for type II (27.8%) OR 3.4 (1.1 A 10.5), p = 0.03, 5 for type III (27.8%) OR 3.4 (1.1 A 10.5) p = 0.03, 4 for type IV (8.7%) p = 0.76, 2 for type V (4.4%) p = 0.24. Conclusions: Rate of HAT is similar compared with the reported in literature. Any type of aortic by pass is related with increased risk of HAT.
EP05A-028 RISK ANALYSIS FOR OUTCOMES FROM THE USE OF AORTOHEPATIC CONDUIT IN ORTHOTOPIC LIVER TRANSPLANTATION N. A. Chatzizacharias1, M. Aly1, E. Godfrey2, S. Harper1, E. Huguet1, A. Jah1 and R. K. Praseedom1 1 HPB and Transplant Surgery, and 2Radiology, Addenbrooke’s Hospital, University of Cambridge, United Kingdom Introduction: The use of aortohepatic conduit (AHC) in orthotopic liver transplantation (OLT) is associated with higher complication rates and especially higher risk for hepatic arterial thrombosis (HAT). This study is an analysis of potential risk factors affecting outcomes after AHC use in OLT. Methods: This is a retrospective, single centre analysis of prospectively collected data on cases performed over a 12year period. Patient and graft survival were estimated using the KaplaneMeier method. Risk factor analysis for patient, graft survival and HAT was performed using univariate and multivariate Cox regression. Results: Eighty-six patients received 92 grafts using AHC. Median follow-up was 44 months. Overall complication rate was 33.7%, with 16.3% conduit-related complications. Twenty deaths were recorded, with 65.7% patient survival at 12 years. Multivariate analysis identified aberrant graft arterial anatomy, previous OLT, previous AHC use, need for platelets transfusion, reperfusion time and secondary warm ischaemia time as independent prognostic factors. Nineteen grafts failed, including 10 due to conduitrelated complications. Graft survival at 12 years was 67.3%. Multivariate analysis identified MELD, HAT (strongest factor, p < 0.001) and inferior vena cava stenosis post-OLT as independent prognostic factors. HAT rate was 11.9%. Multivariate analysis identified female gender, metabolic disease and non-alcoholic steatohepatitis as aetiology of liver failure, pre-OLT severe portal hypertension, bleeding complications, cold
ischaemia time and donor body mass index as independent prognostic factors. Conclusion: The use of AHC is a useful technique in OLT with acceptable long-term patient and graft survival, despite an increased risk for HAT and other post-operative complications.
EP05A-030 IMPACT OF DONOR AND RECIPIENT AGE ON SHORT- AND LONG-TERM OUTCOMES AFTER ADULT LIVING DONOR LIVER TRANSPLANTATION T. Hibi, M. Shinoda, T. Minagawa, O. Itano, H. Obara, M. Kitago, Y. Abe, H. Yagi, K. Matsubara and Y. Kitagawa Department of Surgery, Keio University School of Medicine, Japan Introduction: Age has been considered as a significant risk factor in liver transplantation. However, several transplant centers have recently described equivalent outcomes after living donor liver transplantation (LDLT) between elderly and young donors or recipients. We aimed to identify the impact of age on LDLT in our institution. Method: We conducted a retrospective cohort analysis to define donor and recipient factors associated with 6-month mortality among patients who underwent adult LDLT (2005e2014). After excluding all 6-month mortality cases, we performed log-rank tests and Cox multivariate analyses to delineate prognostic indicators of 5-year survival. Donors and recipients were stratified with each 5-year increment of age. Results: Of 89 adult LDLT cases, hepatitis C-related cirrhosis (34%, n = 30) was the most common etiology. ABO-incompatible, 39% (n = 35); Graft-Recipient Weight Ratio <0.7, 21% (n = 19); median recipient age, 51 (19e 67) years (60 years, 21%); median donor age, 38 (20e65) years (60 years, 7%). Three factors that independently correlated with 6-month mortality (n = 13, 13%) were: MELD 25 < Odds ratio (OR) 8.2, 95% confidence interval (CI) 1.8e37.4>, hepaticojejunostomy (OR 10.1, 95% CI 1.8e57.1), and recipient + donor age > 110 (OR 9.0, 95% CI 1.4e56.4). Five-year overall survival was 75% (median follow-up, 54 months). Hepatitis C < hazard ratio (HR) 10.0, 95% CI 1.2e83.4> and donor age >50 years (HR 5.3, 95% CI 1.2e24.2) were independent indicators of decreased survival. Conclusion: Recipient age by itself is not a poor prognostic factor in adult LDLT. Indication and timing of LDLT and donor selection should be individually tailored to improve outcomes.
EP05A-031 RETRANSPLANTATION FOR GRAFT FAILURE MORE THAN 5 YEARS AFTER PRIMARY LIVER TRANSPLANT S. H. Tsang1, S. C. Chan1, W. C. Dai1, K. S. H. Chok1, T. T. Cheung1, W. W. Sharr1, A. C. Y. Chan1, J. Y. Y. Fung2, T. C. L. Wong1, S. L. Sin1 and C. M. Lo1 1 Department of Surgery, and 2Department of Medicine, University of Hong Kong, Hong Kong
HPB 2016, 18 (S1), e385ee601
Electronic Poster Abstracts Introduction: Graft failure is a much feared complication after liver transplantation, and retransplant is often indicated. Little is known about the outcome following retransplants which take place more than 5 years after the first. Methods: This is a retrospective study of liver retransplants performed by a single centre between 1996 and 2013; which the retransplant was performed more than 60 months after the first. The retransplants were divided into a deceased donor group (DD) and a living donor group (LD). We analyzed their perioperative parameters and survival outcomes. Results: There were 10 patients in the DD group and 6 patients in the LD group. Biliary complications, chronic rejection and recurrent hepatitis C infection were the main indications for retransplantation. The LD group had a significantly longer intensive care unit stay of 23 days compared with 4 days in the DD group (P = 0.004); also a longer hospital stay of 42 days compared with 18 days in the DD group (P = 0.034). The two groups had comparable preoperative MELD score, intraoperative blood loss, transfusion requirement, operating time and complication rate. There were 2 hospital mortalities in the DD group but none in the LD group. Patient survival at 5 years was 100% in the LD group and 80% in the DD group (P = 0.260). No patient in either group has died after discharge from hospital following retransplant. Conclusion: Long term survival is excellent after liver retransplantation when the retransplant takes place more than 5 years after the first.
EP05A-032 SIMULTANEOUS VERSUS SEQUENTIAL REVASCULARISATION OF THE LIVER GRAFT IN SPLIT LIVER TRANSPLANTATION C. Goumard1, F. Perdigao2, F. Vicentine2, R. Brustia2, A. Sepulveda3, O. Soubrane3 and O. Scatton2 1 Université Pierre et Marie Curie, Hôpital la Pitié Salpêtrière, 2Hepatobiliary Surgery and Liver Transplantation, Université Pierre et Marie Curie, Hôpital la Pitié Salpêtrière, and 3Hepatobiliopancreatic Surgery and Liver Transplantation, Hôpital Beaujon, France Introduction: The technical sequence of graft revascularization during liver transplantation (LT) isn’t standardized. Sequential revascularization makes arterial anastomosis (AA) more challenging due to arterial backflow, especially in split LT (SLT), considering the small vessel’s diameter and liver cut surface bleeding. Our aim was to evaluate simultaneous versus sequential revascularization in SLT. Methods: All adults undergoing SLT with right liver grafts from May 2000 to January 2014 were included and divided in two groups: Sequential revascularization (SEQ), where AA was performed after vena cava and portal declamping, versus simultaneous (SIM), where AA was performed before venous declamping. Patients’ characteristics, blood transfusion requirement, and postoperative course were analyzed. Results: 57 patients underwent SLT, including 14 SIM (24.5%) and 43 SEQ (75.5%). Patient’s characteristics were comparable. Operative time was significantly shorter in SIM group (388 vs 475 min, p = 0.018). Cold ischemia time and anhepatic phase were longer in SIM group (693 vs 637 min, p = 0.046 and 87 vs 69 min, p = 0.021). No difference was found in blood transfusion (50% vs 51%,
HPB 2016, 18 (S1), e385ee601
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p = 0.64). No arterial thrombosis occurred in SIM group (n = 0 vs n = 7 in SEQ group, p = 0.12). All patients in SIM group received antiagregant treatment, versus 19 in SEQ (p < 0.005). Patient and graft survival at 90 days were 100% in SIM group, versus 90% in SEQ (p = NS). Conclusion: SIM vascular reperfusion compared to SEQ in SLT allows better technical conditions for arterial anastomosis with shorter duration of LT, without any impact on postoperative course or graft survival, despite a longer cold ischemia time.
EP05A-033 INTERLEUKIN 6 AT REPERFUSION: A POWERFUL VERY EARLY PROGNOSTIC FACTOR IN LIVER TRANSPLANTATION F. Faitot, P. Addeo, V. De Blasi, E. Housseau, C. Besch, B. Ellero, M. -L. Woehl-Jaegle and P. Bachellier Hopitaux Universitaire de Strasbourg, France Introduction: The goal of this study was to evaluate the prognostic impact of systemic interleukin 6 (IL6) harvested 30 minutes after portal reperfusion. Method: All consecutive liver transplantation (LT) between 2009 and 2013 for which IL6 was measured 30 minutes after portal reperfusion were included. Systemic IL6 was measured at the same time as liver tests and arterial lactates. Correlation between IL6 levels and short and longterm outcomes was evaluated. A threshold of 1000 ng/ml IL6 at reperfusion was used in KaplaneMeier survival analysis and multivariate analysis. Results: 225 patients were available for analysis during the study period. The mean MELD score at listing was 21 5 and the median waiting time 191 days (0e1715). The main indication for LT was alcoholic cirrhosis (n = 103) followed by hepatitis C (n = 31). Mean IL6 at reperfusion was 1335 262 ng/ml. IL6 at reperfusion was not correlated to preLT MELD score. It was correlated neither to cold ischemia time, K+, ASAT or ALAT at reperfusion. Its level was correlated to systemic lactates (p = 0.035). Most interestingly, IL6 predicted transfusion needs, 30 and 90-days mortality, biliary complications, postoperative ascites and renal insufficiency. An IL6 level >1000 ng/ml predicted overall survival (p = 0.004) and graft survival (p = 0.001). Conclusion: High IL6 level at reperfusion is a very early marker of short- and long-term outcome in liver transplantation. Further studies could use this tool to determine where does this major inflammatory response come and its determinants as they could be interventional targets to enhance the results of LT.
EP05A-035 SURGICAL RESECTION OF HEPATIC METASTASIS OF HEPATOCELLULAR CARCINOMA AFTER LIVER TRANSPLANTATION, A CASE REPORT AND LITERATURE REVIEW S. Perales1, E. C. Ataide2, I. Filardi2, A. S. Magnani2, C. Escanhoela2 and I. Boin2 1 Liver Transplantation, and 2UNICAMP, Brazil
Electronic Poster Abstracts
Methods: Demographic and surgical data of patients transplanted between 1996 and February 2015 were analyzed. A classification was made: Type I: end-to-end hepatic anastomosis; type II: direct end-to-side aortic anastomosis; type III: iliac by-pass to the aorta; type IV: end-to-end anastomosis in living donor graft (LDG); type V: multiple vascular anastomoses; type VI: use of vascular prosthesis. Rate of HAT was determined for each type of anastomosis and Odds Ratio (two-tailed Fisher exact test) was analyzed. Results: 207 PLT were performed in 171 patients, 90 males, median age 5.5 years. Type of anastomosis; Type I 80 (38.6%), type II 18 (8.7%), type III 18 (8.7%), type IV 46 (22.2%), type V 45 (21.7%) Type VI 0. There were 21 HAT (10.1%), 13 (61.9%) were successfully revascularized, 8 required retransplantation. Rate of HAT was 5 for type I (6.3%) p = 0.37, 5 for type II (27.8%) OR 3.4 (1.1 A 10.5), p = 0.03, 5 for type III (27.8%) OR 3.4 (1.1 A 10.5) p = 0.03, 4 for type IV (8.7%) p = 0.76, 2 for type V (4.4%) p = 0.24. Conclusions: Rate of HAT is similar compared with the reported in literature. Any type of aortic by pass is related with increased risk of HAT.
EP05A-028 RISK ANALYSIS FOR OUTCOMES FROM THE USE OF AORTOHEPATIC CONDUIT IN ORTHOTOPIC LIVER TRANSPLANTATION N. A. Chatzizacharias1, M. Aly1, E. Godfrey2, S. Harper1, E. Huguet1, A. Jah1 and R. K. Praseedom1 1 HPB and Transplant Surgery, and 2Radiology, Addenbrooke’s Hospital, University of Cambridge, United Kingdom Introduction: The use of aortohepatic conduit (AHC) in orthotopic liver transplantation (OLT) is associated with higher complication rates and especially higher risk for hepatic arterial thrombosis (HAT). This study is an analysis of potential risk factors affecting outcomes after AHC use in OLT. Methods: This is a retrospective, single centre analysis of prospectively collected data on cases performed over a 12year period. Patient and graft survival were estimated using the KaplaneMeier method. Risk factor analysis for patient, graft survival and HAT was performed using univariate and multivariate Cox regression. Results: Eighty-six patients received 92 grafts using AHC. Median follow-up was 44 months. Overall complication rate was 33.7%, with 16.3% conduit-related complications. Twenty deaths were recorded, with 65.7% patient survival at 12 years. Multivariate analysis identified aberrant graft arterial anatomy, previous OLT, previous AHC use, need for platelets transfusion, reperfusion time and secondary warm ischaemia time as independent prognostic factors. Nineteen grafts failed, including 10 due to conduitrelated complications. Graft survival at 12 years was 67.3%. Multivariate analysis identified MELD, HAT (strongest factor, p < 0.001) and inferior vena cava stenosis post-OLT as independent prognostic factors. HAT rate was 11.9%. Multivariate analysis identified female gender, metabolic disease and non-alcoholic steatohepatitis as aetiology of liver failure, pre-OLT severe portal hypertension, bleeding complications, cold
ischaemia time and donor body mass index as independent prognostic factors. Conclusion: The use of AHC is a useful technique in OLT with acceptable long-term patient and graft survival, despite an increased risk for HAT and other post-operative complications.
EP05A-030 IMPACT OF DONOR AND RECIPIENT AGE ON SHORT- AND LONG-TERM OUTCOMES AFTER ADULT LIVING DONOR LIVER TRANSPLANTATION T. Hibi, M. Shinoda, T. Minagawa, O. Itano, H. Obara, M. Kitago, Y. Abe, H. Yagi, K. Matsubara and Y. Kitagawa Department of Surgery, Keio University School of Medicine, Japan Introduction: Age has been considered as a significant risk factor in liver transplantation. However, several transplant centers have recently described equivalent outcomes after living donor liver transplantation (LDLT) between elderly and young donors or recipients. We aimed to identify the impact of age on LDLT in our institution. Method: We conducted a retrospective cohort analysis to define donor and recipient factors associated with 6-month mortality among patients who underwent adult LDLT (2005e2014). After excluding all 6-month mortality cases, we performed log-rank tests and Cox multivariate analyses to delineate prognostic indicators of 5-year survival. Donors and recipients were stratified with each 5-year increment of age. Results: Of 89 adult LDLT cases, hepatitis C-related cirrhosis (34%, n = 30) was the most common etiology. ABO-incompatible, 39% (n = 35); Graft-Recipient Weight Ratio <0.7, 21% (n = 19); median recipient age, 51 (19e 67) years (60 years, 21%); median donor age, 38 (20e65) years (60 years, 7%). Three factors that independently correlated with 6-month mortality (n = 13, 13%) were: MELD 25 < Odds ratio (OR) 8.2, 95% confidence interval (CI) 1.8e37.4>, hepaticojejunostomy (OR 10.1, 95% CI 1.8e57.1), and recipient + donor age > 110 (OR 9.0, 95% CI 1.4e56.4). Five-year overall survival was 75% (median follow-up, 54 months). Hepatitis C < hazard ratio (HR) 10.0, 95% CI 1.2e83.4> and donor age >50 years (HR 5.3, 95% CI 1.2e24.2) were independent indicators of decreased survival. Conclusion: Recipient age by itself is not a poor prognostic factor in adult LDLT. Indication and timing of LDLT and donor selection should be individually tailored to improve outcomes.
EP05A-031 RETRANSPLANTATION FOR GRAFT FAILURE MORE THAN 5 YEARS AFTER PRIMARY LIVER TRANSPLANT S. H. Tsang1, S. C. Chan1, W. C. Dai1, K. S. H. Chok1, T. T. Cheung1, W. W. Sharr1, A. C. Y. Chan1, J. Y. Y. Fung2, T. C. L. Wong1, S. L. Sin1 and C. M. Lo1 1 Department of Surgery, and 2Department of Medicine, University of Hong Kong, Hong Kong
HPB 2016, 18 (S1), e385ee601
Electronic Poster Abstracts Introduction: Graft failure is a much feared complication after liver transplantation, and retransplant is often indicated. Little is known about the outcome following retransplants which take place more than 5 years after the first. Methods: This is a retrospective study of liver retransplants performed by a single centre between 1996 and 2013; which the retransplant was performed more than 60 months after the first. The retransplants were divided into a deceased donor group (DD) and a living donor group (LD). We analyzed their perioperative parameters and survival outcomes. Results: There were 10 patients in the DD group and 6 patients in the LD group. Biliary complications, chronic rejection and recurrent hepatitis C infection were the main indications for retransplantation. The LD group had a significantly longer intensive care unit stay of 23 days compared with 4 days in the DD group (P = 0.004); also a longer hospital stay of 42 days compared with 18 days in the DD group (P = 0.034). The two groups had comparable preoperative MELD score, intraoperative blood loss, transfusion requirement, operating time and complication rate. There were 2 hospital mortalities in the DD group but none in the LD group. Patient survival at 5 years was 100% in the LD group and 80% in the DD group (P = 0.260). No patient in either group has died after discharge from hospital following retransplant. Conclusion: Long term survival is excellent after liver retransplantation when the retransplant takes place more than 5 years after the first.
EP05A-032 SIMULTANEOUS VERSUS SEQUENTIAL REVASCULARISATION OF THE LIVER GRAFT IN SPLIT LIVER TRANSPLANTATION C. Goumard1, F. Perdigao2, F. Vicentine2, R. Brustia2, A. Sepulveda3, O. Soubrane3 and O. Scatton2 1 Université Pierre et Marie Curie, Hôpital la Pitié Salpêtrière, 2Hepatobiliary Surgery and Liver Transplantation, Université Pierre et Marie Curie, Hôpital la Pitié Salpêtrière, and 3Hepatobiliopancreatic Surgery and Liver Transplantation, Hôpital Beaujon, France Introduction: The technical sequence of graft revascularization during liver transplantation (LT) isn’t standardized. Sequential revascularization makes arterial anastomosis (AA) more challenging due to arterial backflow, especially in split LT (SLT), considering the small vessel’s diameter and liver cut surface bleeding. Our aim was to evaluate simultaneous versus sequential revascularization in SLT. Methods: All adults undergoing SLT with right liver grafts from May 2000 to January 2014 were included and divided in two groups: Sequential revascularization (SEQ), where AA was performed after vena cava and portal declamping, versus simultaneous (SIM), where AA was performed before venous declamping. Patients’ characteristics, blood transfusion requirement, and postoperative course were analyzed. Results: 57 patients underwent SLT, including 14 SIM (24.5%) and 43 SEQ (75.5%). Patient’s characteristics were comparable. Operative time was significantly shorter in SIM group (388 vs 475 min, p = 0.018). Cold ischemia time and anhepatic phase were longer in SIM group (693 vs 637 min, p = 0.046 and 87 vs 69 min, p = 0.021). No difference was found in blood transfusion (50% vs 51%,
HPB 2016, 18 (S1), e385ee601
e551
p = 0.64). No arterial thrombosis occurred in SIM group (n = 0 vs n = 7 in SEQ group, p = 0.12). All patients in SIM group received antiagregant treatment, versus 19 in SEQ (p < 0.005). Patient and graft survival at 90 days were 100% in SIM group, versus 90% in SEQ (p = NS). Conclusion: SIM vascular reperfusion compared to SEQ in SLT allows better technical conditions for arterial anastomosis with shorter duration of LT, without any impact on postoperative course or graft survival, despite a longer cold ischemia time.
EP05A-033 INTERLEUKIN 6 AT REPERFUSION: A POWERFUL VERY EARLY PROGNOSTIC FACTOR IN LIVER TRANSPLANTATION F. Faitot, P. Addeo, V. De Blasi, E. Housseau, C. Besch, B. Ellero, M. -L. Woehl-Jaegle and P. Bachellier Hopitaux Universitaire de Strasbourg, France Introduction: The goal of this study was to evaluate the prognostic impact of systemic interleukin 6 (IL6) harvested 30 minutes after portal reperfusion. Method: All consecutive liver transplantation (LT) between 2009 and 2013 for which IL6 was measured 30 minutes after portal reperfusion were included. Systemic IL6 was measured at the same time as liver tests and arterial lactates. Correlation between IL6 levels and short and longterm outcomes was evaluated. A threshold of 1000 ng/ml IL6 at reperfusion was used in KaplaneMeier survival analysis and multivariate analysis. Results: 225 patients were available for analysis during the study period. The mean MELD score at listing was 21 5 and the median waiting time 191 days (0e1715). The main indication for LT was alcoholic cirrhosis (n = 103) followed by hepatitis C (n = 31). Mean IL6 at reperfusion was 1335 262 ng/ml. IL6 at reperfusion was not correlated to preLT MELD score. It was correlated neither to cold ischemia time, K+, ASAT or ALAT at reperfusion. Its level was correlated to systemic lactates (p = 0.035). Most interestingly, IL6 predicted transfusion needs, 30 and 90-days mortality, biliary complications, postoperative ascites and renal insufficiency. An IL6 level >1000 ng/ml predicted overall survival (p = 0.004) and graft survival (p = 0.001). Conclusion: High IL6 level at reperfusion is a very early marker of short- and long-term outcome in liver transplantation. Further studies could use this tool to determine where does this major inflammatory response come and its determinants as they could be interventional targets to enhance the results of LT.
EP05A-035 SURGICAL RESECTION OF HEPATIC METASTASIS OF HEPATOCELLULAR CARCINOMA AFTER LIVER TRANSPLANTATION, A CASE REPORT AND LITERATURE REVIEW S. Perales1, E. C. Ataide2, I. Filardi2, A. S. Magnani2, C. Escanhoela2 and I. Boin2 1 Liver Transplantation, and 2UNICAMP, Brazil