Surgical Categorization Improve Outcomes and Organ Utilization in Liver Transplantation

Abstract

Background Liver transplant (LT) varies greatly in technical complexity due to factors such as prior surgery, obesity, and portal vein thrombosis (PVT). In addition, our program often evaluates ‘orphan livers’ that require a quick, effective and accurate recipient selection. This must be taken into account when considering organ offers. In 2015, we began using an A/B/C stratification of predicted surgical complexity based on surgical history and cross-sectional imaging, as reviewed by faculty surgeons. The scores are assigned at waitlist addition and are integral to on-call workflow at the time of the liver offer. Methods Four-hundred consecutives LT recipients (Jan-15 to Dec-16) were prospectively categorize at the time of listing according with their surgical complexity in Group A: Low (n=268) LT alone, absence-moderate obesity; patent PV, no upper abdomen surgeries (except lap chole); Group B: Moderate (n=91) combined LKT, moderate–severe obesity, upper abdomen operations, PV thrombosis; and Group C: High (n=41) retransplantation, previous HB surgery or gastric bypass, PV cavernous transformation. Analysis were performed using Student t-test and Fisher exact test. Survival curves were obtained by Kaplan Meier method and log rank test. Results are in Mean + SD and Mead IQ 1-3. Results Recipients in group A had lower MELD (19.5+8.3 vs. 20.4+9.3 vs. 24.8+9.6 P=0.001) while recipients in group B had higher BMI (27.2+5.4 vs. 33.1+8 vs. 26.9+5.1 p=0.002) and high proportion of HCC (32% vs. 46% vs. 17% p=0.02). Group C had the higher incidence of previous LT (2.4% vs. 1.1% vs. 26.8% p<0.001), PV thrombosis (7.8% vs. 12% vs. 29% p=0.002) and its operation time was longer (5.3+1.6 vs. 5.5+1.3 vs. 6.4+2.1 p<0.001), ICU stay (median, IQ 2, 2-4 vs. 2.8, 2-4 vs. 3, 2-5 days p=0.001) and hospital stay (Median IQ 6, 6-14 vs. 11, 7-18 vs. 12, 8-28 days, p=0.001). All three groups had similar cold ischemia time (33.2+96 vs. 317+84 vs. 312.5+89.9 min, p=0.8) but compared with group B, group A received a higher proportion of livers from out our donor service area (57.8% vs. 43.9% vs. 58.9% p=0.001). In addition, group A received more DCD livers (12.7% vs. 5.5% vs. 0% p=0.02) and higher donor risk index livers (1.6+0.4 vs. 1.4+0.4 vs. 1.3+0.2 p<0.001). Donor liver steatosis, incidence of early allograft dysfunction and, biliary and vascular complications were similar in all 3 groups. One-year graft and patient survival were 91.8% vs. 87.9% vs. 78.1% (p=0.006) and 93.3% vs. 91.2% vs. 78.1% (p=0.001) for groups A, B, C respectively. Conclusion Pre LT categorization by surgical complexity at the time of listing correctly stratified patients’ surgical risk. Surgical complexity ranking is a tool that allows better recipient selection, recipient-donor matching and resource utilization that result in increase acceptance of liver offers.