Liver Transplantation Procedures Research Articles

MO398DETERIORATION OF RENAL OUTCOMES AND INCREASED MORTALITY RISK DUE TO ACUTE KIDNEY INJURY AFTER ORTHOTOPIC LIVER TRANSPLANTATION: SYSTEMATIC REVIEW AND META-ANALYSIS OF COHORT STUDIES

Abstract Background and Aims Orthotopic liver transplantation (OLT) procedure is increased as incremental end-stage liver disease patients’ prevalence. Acute kidney injury (AKI) is one of most common post-OLT complications that is associated with poor renal outcomes and increased mortality risk although the results are still inconclusive. This study aims to measure the risk of deterioration of renal outcomes and mortality risk due to AKI incidence in post-OLT patients. Method We did comprehensive searching using predefined terms in online databases of Pubmed, EMBASE, ScienceDirect, and The Cochrane Library, to include all relevant studies from 2000-2020. We included all cohort studies that reported AKI incidence in post-OLT patients and accessed the risk of 3-month renal replacement therapy (RRT) need, 1-year chronic kidney disease (CKD) progression, and 1-year mortality rate. We used The Newcastle-Ottawa Scale for cohort study for accessing bias risk. We conducted analysis to pooled risk ratio (RR) with 95% confidence interval (CI) using random-effect heterogeneity test. Results We included 10 cohort studies met our inclusion criteria. The AKI incidence significantly both increases the need of RRT in post-OLT patients (pooled RR = 8.41. 95% CI = 2.82 to 25.09, p = 0.0001, I2 = 0%) then leads the CKD progression in one year (pooled RR = 6.76. 95% CI = 2.03 to 22.51, p = 0.002, I2 = 84%). The post-OLT patients who suffered from AKI has significant incremental 1-year mortality risk (pooled RR = 7.27. 95% CI = 4.34 to 12.18, p<0.00001, I2 = 5%). Conclusion The incidence of AKI in post-OLT patients significantly increase the deterioration of renal outcomes and mortality risks. However, further trials are needed to establish the causalities.

Impact of Anesthesiologist Experience on Early Outcomes in Adult Orthotopic Liver Transplantation

Liver transplantation is a complex surgical procedure. The experience of the anesthesiologist, and its potential relationship to patient morbidity and mortality, is yet to be determined. We sought to explore this possible association using our institutional training patterns as the subject of study. This is a single center retrospective analysis investigating the association of an anesthesiologist's experience with liver transplantation and its potential effect on early patient outcomes in adult liver transplant recipients from January 2010 to September 2016. Training of team members consisted of a 6-month period of clinical shadowing with a senior anesthesiologist and co-staffing 8 liver transplant procedures before solo staffing a liver transplant. Specifically, patient outcomes for the first 5 transplants after this training were investigated. The only independent risk factor for early death or early graft loss was the amount of packed red blood cells administered during transplantation. With respect to secondary outcomes, the amount of packed red blood cells and hospitalization at the time of transplant were associated with the number of days on a ventilator, length of intensive care unit stay, and overall hospital length of stay. The results of this study conclude that the training model currently in place for our new team members has no negative impact on patient outcomes after liver transplantation.

Rates and causative pathogens of surgical site infections attributed to liver transplant procedures and other hepatic, biliary, or pancreatic procedures, 2015‐2018

Liver transplant recipients are at high risk for surgical site infections (SSIs). Limited data are available on SSI epidemiology following liver transplant procedures (LTPs). We analyzed data on SSIs from 2015 to 2018 reported to CDC's National Healthcare Safety Network to determine rates, pathogen distribution, and antimicrobial resistance after LTPs and other hepatic, biliary, or pancreatic procedures (BILIs). LTP and BILI SSI rates were 5.7% and 5.9%, respectively. The odds of SSI after LTP were lower than after BILI (adjusted odds ratio = 0.70, 95% confidence interval 0.57‐0.85). Among LTP SSIs, 43.1% were caused by Enterococcus spp., 17.2% by Candida spp., and 15.0% by coagulase‐negative Staphylococcus spp. (CNS). Percentages of SSIs caused by Enterococcus faecium or CNS were higher after LTPs than BILIs, whereas percentages of SSIs caused by Enterobacteriaceae, Enterococcus faecalis, or viridans streptococci were higher after BILIs. Antimicrobial resistance was common in LTP SSI pathogens, including E. faecium (69.4% vancomycin resistant); Escherichia coli (68.8% fluoroquinolone non‐susceptible and 44.7% extended spectrum cephalosporin [ESC] non‐susceptible); and Klebsiella pneumoniae and K. oxytoca (39.4% fluoroquinolone non‐susceptible and 54.5% ESC non‐susceptible). National LTP SSI pathogen and resistance data can help prioritize studies to determine effective interventions to prevent SSIs and reduce antimicrobial resistance in liver transplant recipients.

Pediatric split liver transplantation for congenital factor X deficiency: first 10-year follow-up of a case with portal vein stenting

Congenital factor X (FX) deficiency is a rare autosomal-recessive disease that induces bleeding disorder. Herein, we present the 10-year posttransplant course of a pediatric patient who underwent liver transplantation (LT) with portal vein (PV) stenting for correction of severe congenital FX deficiency, with focus on long-term maintenance of coagulation function and patency of PV stenting. A 17-month-old infant with recurrent hemorrhagic episodes due to FX deficiency underwent split LT using a left lateral section graft. The graft-recipient weight ratio was 2.2%. The graft implantation procedures were performed by following the standard pediatric split LT procedure. Nevertheless, a wall stent was inserted due to PV anastomotic stenosis on posttransplant day 1. Graft function recovered slowly because of partial parenchyma infarct, and the patient was discharged at 46 days after LT operation. The FX activity started to increase soon after LT and gradually normalized; the coagulation profiles have been maintained well for the past 10 years. The patient has been doing well for the past 10 years after LT without any episodes of abnormal bleeding. Due to the risk of vascular complications owed to PV stenting, life-long follow-up is mandatory with special attention until attainment of complete physical growth to adolescent and adulthood.

Learning Gains of Liver Resection and Transplantation Workshop on Genelyn® Embalmed Human Cadavers: Surgical Gastroenterologists’ Perceptions

In the light of increased requirement for liver transplantation procedures, it is pertinent to develop bankable human expertise in the areas of liver resection and anastomoses. The alternative simulator sources available for learning surgical skills might not always provide the realistic learning gains as provided by human cadavers, especially in terms of haptic and tactile fidelity. For the first time, we have used Genelyn® embalmed cadavers (GEC) for training the surgical gastroenterologists in liver resection and transplantation procedures and we wish to document our experience of using them to facilitate the learning of liver resection procedures. A cross-sectional satisfaction survey fitting to the first level of the Kirkpatrick model for training evaluation was performed among participating surgical gastroenterologists of liver resection and transplantation training workshop using GEC. Visual, haptic and tactile characteristics of the liver and related structures were assessed along with overall satisfaction of the workshop. Eleven surgical gastroenterologists had participated in the workshop conducted using three GEC. Nine participants agreed that the transection of liver parenchyma was similar to reality. However, two opined that the liver parenchyma was a bit harder to resect. Identification of portal pedicle, dissection of the peri-portal area and securing vascular anastomoses also had an acceptable level of similarity to real life. The two parameters that received a unanimous degree of the agreement are mobilization of liver and cannulation of key vessels for perfusion. Participants of the cadaveric surgical skills training workshop opined that the soft-embalmed cadaver using Genelyn® is an excellent realistic model for practicing liver resection and transplantation surgery.

Using Glissonian sheath as an alternative way to prevent biliary stricture in living-donor liver transplantation

/Objective: The aim of this study was to report a single-institution experience involving a Glissonian sheath-to-duct method for biliary reconstruction in living donor liver transplantation, focusing on the association between surgical techniques and biliary stricture rates. Three hundred and twenty adult right lobar living donor liver transplantation procedures were analyzed through a comparison of 200 Glissonian sheath-to-duct (GD) reconstructions and 120 duct-to-duct (DD) reconstructions in biliary anastomosis. At a mean follow-up period of 60.8 months, the GD group had a significantly lower biliary stricture rate (13.5%, 27/200) than the DD group (26.7%, 32/120) (p=0.003). In biliary anastomosis with single duct anastomosis, the incidence of biliary stricture was significantly greater for the DD group (17/79, 21.5%) than for the GD group (14/141, 9.9%) (p=0.018). This study has shown that GD anastomosis of the bile duct produced outstanding results with respect to the reduction of biliary stricture. The GD technique can therefore be suggested as an alternative method for biliary reconstruction in LDLT.

Proctalgia secondary to rectal arteriovenous malformation and inferior mesenteric vein stenosis in a patient post liver transplant

BackgroundChronic proctalgia can have a major impact upon quality of life. There are many potential aetiologies however, in some patients no cause can be identified.Case presentationWe present a patient post liver transplant with intractable proctalgia, despite multidisciplinary management including opioids, nerve blocks and surgical intervention. An underlying rectal arteriovenous malformation (AVM) was subsequently identified and successfully treated with embolotherapy. The onset of symptoms coincided with the development of inferior mesenteric vein stenosis, likely leading to engorgement of the malformation due to impaired venous outflow. Neovascularisation secondary to the liver transplant procedure may also have contributed to growth of the lesion.ConclusionThis is a rare presentation of rectal AVM. These lesions can be treated with minimally invasive embolisation/sclerotherapy and should be considered in cases of unexplained proctalgia.

Liver Transplantation for Metabolic Liver Disease Patients: A Single-Center Experience

Introduction: Metabolic liver disease (MLD) is life threatening. The efficacy of liver transplantation (LT) for MLD patients are well reported. There are some options of surgical procedures, but a few reports of collecting data was reported from a single-center. Here we present our experiences of LT procedures including deceased donor (DD) LT, living donor (LD) LT and auxiliary partial orthotopic liver transplantation (APOLT), and outcome in those patients. Methods: Medical records of 61 MLD adult (≧18 years old) recipients underwent LT in our institute were reviewed retrospectively. Perioperative factors were investigated. The patient survival rate was calculated. Results: The causes of LT were familial amyloid polyneuropathy in 42, adult-onset type 2 citrullinemia in 17, glycogen storage disease in 1 and Wilson's disease in 1. The median age at LT was 37.1 (range 18.8 to 58.4) years old. All DDLT recipients received whole liver graft (n=7). In all LDLT cases (n=54), the left liver grafts were used. The median volume of graft was 392g that was correspond to 38.0% of the recipient standard liver volume (range 230 (22.1) to 580g (58.8%)). In 18 cases of those, APOLT was selected because of extremely small size of graft or expectation of future gene therapy. The 10-year survival rate of MLD recipients was 86.8%. Conclusions: Even though a graft is relatively small, LT for MLD patients could be successfully achieved with APOLT. The 10-year survival rate of MLD recipient in our institute was thought to be satisfactory.

Living donor left lateral sectionectomy: Should the procedure still be performed open?

BackgroundThe chronic shortage of organs makes the option of living liver donation particularly appealing, and living donor LLS transplantation remains the most common procedure for pediatric liver transplantation in Russia. Laparoscopic living donor left lateral sectionectomy (lapLDLLS) was recently established as a new standard practice. PurposeThe present retrospective single center study aimed to achieve a greater understanding of when the conventional method could be suitably substituted with the laparoscopic approach and to review the potential advantages obtained. Herein, we describe our experience from the initial implementation to routinely use of the laparoscopic approach. MethodA retrospective review of 127 lapLDLLSs performed between May 2016 and August 2020 at the National Medical Research Center of Transplantation and Artificial Organs, Moscow, Russia was undertaken. A segmented line regression model and receiver operating characteristic analysis based on the operation time were used to determine the learning curve (LC) under the initial proctorship. Donors were divided into two groups: before and after attaining the LC, cases 1–37 and cases 38–127, respectively. The perioperative parameters of donors and recipients in post LC cases were compared to 154 open procedures with propensity score match 1:1. ResultsLC cutoff was determined to occur by the 37th case of lapLDLLS. Subsequently, for the lapLDLLS group compared to the open group, there were significant reductions in the operative time, estimated blood loss, visual analogue pain score on the first and fourth postoperative day, and length of hospital stay (p < 0.001 for each of the comparisons). There were no significant differences between the groups with respect to donor complication rates and recipient outcomes. ConclusionThe laparoscopic approach could be chosen for LLS living donors after achieving the LC, in circumstances where there is a well-developed and proctored program.

Pure Laparoscopic Donor Hepatectomy in Pediatric Living Donor Liver Transplantation: An Appraisal of the Safety and Efficacy of the Procedure

Objective: This study aimed to assess the safety of this procedure in children, including surgical complications and survival outcome following LDLT, to evaluate the effectiveness of open donor hepatectomy versus pure laparoscopic donor hepatectomy in a high-volume LDLT center. Methods: The medical records of 107 patients (aged ≤17 years) who underwent ABO compatible LDLT from May 2008 to June 2016 were analyzed. Of 107 patients, 76 underwent open donor hepatectomy and 31 underwent pure laparoscopic donor hepatectomy. To overcome bias from the differing distribution of co-variables among patients in the two study groups, a 1:1 propensity score matching analysis was performed using the nearest-neighbor matching method. Results: The mean follow-up period was 92.9 months in the open group and 92.7 months in the laparoscopic group. The length of post-operative hospital stay of the donor was statistically shorter in the laparoscopic group than in the open group. The overall surgical complication rate did not differ between the groups. The 1-, 3-, and 5-year overall survival rates were 93.6%, 93.6%, and 93.6% in the open group and 96.8%, 93.6% and 93.6% in the laparoscopic group, respectively. Conclusions: Laparoscopic hepatectomy may be more beneficial for the donor, and the use of laparoscopic methods on the donor does not adversely affect the recipient´s outcome. Thus, laparoscopic hepatectomy is a safe, feasible, and reproducible procedure for pediatric liver transplantation.

SÍNDROME DE TAKOTSUBO EM RECEPTORES DE TRANSPLANTE HEPÁTICO: UMA MINI REVISÃO

Liver transplantation (TxH) is the only effective treatment for terminal liver disease, whether chronic, subacute or acute. The surgical procedure of liver transplantation, the largest current surgery in the human body contributes to the increase of catecholamine concentrations, favoring the occurrence of Takotsubo Syndrome (STK), which is a transient dysfunction of the left ventricle caused by an increase of catecholamines during events of high physiological stress. The importance of considering the diagnosis of STK in the hypothesis formulated for hemodynamic decompensation aims to avoid its complications, especially cardiogenic shock. The management of post-TxH patients with STK is not well established, but there are some strategies described in the literature. The knowledge of the underlying cause for the complications gives greater efficacy to the therapeutic measures to be chosen, providing good evolution to the TxH receptors with STK.

Providing Arterial Supply to the Liver Graft with Recipient Splenic Artery in Living Donor Liver Transplantation: Case Report

Hepatic arterial reconstruction is an important step in graft implantation in liver transplant procedure. Hepatic arterial anastomosis always demands meticulous and highly skilled surgical techniques to provide adequate blood supply to the graft. Hepatic arterial intimal dissection in liver transplantation is although a rare but documented complication, with incidence of less than 5%, but having dreadful complications. To overcome this complication of Recipient hepatic artery dissection, various techniques have been described by different authors. Here, in this case report we are describing technique of utilization of transposed recipient splenic artery for graft arterial inflow where native hepatic artery was dissected up to common hepatic artery. Post-operative recovery was uneventful and on follow up, patient was absolutely fine. So, recipient splenic artery is a safe alternative option in such complex situations for providing arterial blood flow to the graft and moreover it avoids the burden of extra anastomosis which is required in conduit technique.

Long-Term Safety and Efficacy of Pure Laparoscopic Donor Hepatectomy in Pediatric Living Donor Liver Transplantation.

Laparoscopic living donor hepatectomy for transplantation has been well established over the past decade. This study aimed to assess its safety and feasibility in pediatric living donor liver transplantation (LDLT) by comparing the surgical and long‐term survival outcomes on both the donor and recipient sides between open and laparoscopic groups. The medical records of 100 patients (≤17 years old) who underwent ABO‐compatible LDLT using a left lateral liver graft between May 2008 and June 2016 were analyzed. A total of 31 donors who underwent pure laparoscopic hepatectomy and their corresponding recipients were included in the study; 69 patients who underwent open living donor hepatectomy during the same period were included as a comparison group. To overcome bias from the different distributions of covariables among the patients in the 2 study groups, a 1:1 propensity score matching analysis was performed. The mean follow‐up periods were 92.9 and 92.7 months in the open and laparoscopic groups, respectively. The mean postoperative hospital stay of the donors was significantly shorter in the laparoscopic group (8.1 days) than in the open group (10.6 days; P < 0.001). Overall, the surgical complications in the donors and overall survival rate of recipients did not differ between the groups. Our data suggest that the laparoscopic environment was not associated with long‐term graft survival during pediatric LDLT. In addition, the laparoscopic approach for the donors did not adversely affect the corresponding recipient's outcome. Laparoscopic left lateral sectionectomy for living donors is a safe, feasible, and reproducible procedure for pediatric liver transplantation.

Reuse of liver allograft from a brain-dead recipient: a case report

We report our first case of deceased-donor liver transplantation (LT) using a reuse liver graft after the first LT. The recipient was a 38-year-old female with fulminant hepatic failure from toxic hepatitis. She had a history of herb intake and her liver function deteriorated progressively. She was enrolled as the Korean Network for Organ Sharing (KONOS) status 1 and the model for end-stage liver disease score was 34. The donor was a 42-year-old male patient who fell into brain death after LT for alcoholic liver cirrhosis. Donation of multiple organs including the transplanted liver graft was performed 10 days after the first LT operation. Since the liver graft appeared to be normal and frozen-section liver biopsy showed only mild fatty changes, we decided to reuse the liver graft. A modified piggy-back technique of the suprahepatic inferior vena cava reconstruction was used. Other surgical procedures were comparable to the standard deceased-donor LT procedures. The explant liver pathology revealed submassive hepatic necrosis, which was compatible with toxic hepatitis. The peak of serum liver enzyme levels were aspartate transaminase 1,063 IU/L and alanine transaminase 512 IU/L at posttransplant day 3. Since the pretransplant general condition of the recipient was very poor, hospital stay was prolonged and she was discharged 51 days after LT operation. She is currently doing well for 3 years to date. Experience in our case and the literature review suggest that a reuse liver graft can be regarded as one of the marginal grafts which can be transplantable to the LT candidates requiring urgent LT.

Cirrhotic Cardiomyopathy-A Veiled Threat.

Cirrhotic cardiomyopathy (CCM) is defined as cardiac dysfunction in patients with liver cirrhosis without preexisting cardiac disease. According to the definition established by the World Congress of Gasteroenterology in 2005, the diagnosis of CCM includes criteria reflecting systolic dysfunction, impaired diastolic relaxation, and electrophysiological disturbances. Because of minimal or even absent clinical symptoms and echocardiographic signs at rest according to the 2005 criteria, CCM diagnosis is often missed or delayed in most clinically stable cirrhotic patients. However, cardiac dysfunction progresses in time and contributes to the pathogenesis of hepatorenal syndrome and increased morbidity and mortality after liver transplantation, surgery, or other invasive procedures in cirrhotic patients. Therefore, a comprehensive cardiovascular assessment using newer techniques for echocardiographic evaluation of systolic and diastolic function, allowing the diagnosis of CCM in the early stage of subclinical cardiovascular dysfunction, should be included in the screening process of liver transplant candidates and patients with cirrhosis in general. The present review aims to summarize the most important pathophysiological aspects of CCM, the usefulness of contemporary cardiovascular imaging techniques and parameters in the diagnosis of CCM, the current therapeutic options, and the importance of early diagnosis of cardiovascular impairment in cirrhotic patients.

Is Routine Prophylaxis Against Pneumocystis jirovecii Needed in Liver Transplantation? A Retrospective Single-Centre Experience and Current Prophylaxis Strategies in Spain.

In liver transplant (LT) recipients, Pneumocystis jirovecii pneumonia (PJP) is most frequently reported before 1992 when immunosuppressive regimens were more intense. It is uncertain whether universal PJP prophylaxis is still applicable in the contemporary LT setting. We aimed to examine the incidence of PJP in LT recipients followed at our institution where routine prophylaxis has never been practiced and to define the prophylaxis strategies currently employed among LT units in Spain. All LT performed from 1990 to October 2019 were retrospectively reviewed and Spanish LT units were queried via email to specify their current prophylaxis strategy. During the study period, 662 LT procedures were carried out on 610 patients. Five cases of PJP were identified, with only one occurring within the first 6 months. The cumulative incidence and incidence rate were 0.82% and 0.99 cases per 1000 person transplant years. All LT units responded, the majority of which provide prophylaxis (80%). Duration of prophylaxis, however, varied significantly. The low incidence of PJP in our unprophylaxed cohort, with most cases occurring beyond the usual recommended period of prophylaxis, questions a one-size-fits-all approach to PJP prophylaxis. A significant heterogeneity in prophylaxis strategies exists among Spanish LT centres.

S3538 Needle Track Seeding in a Patient With Hepatocellular Carcinoma

INTRODUCTION: We present a case of a 56-year-old Caucasian male with a history of CAD, HTN, and HCV who initially presented in 3/2017 with lower extremity edema found to have newly diagnosed systolic heart failure and severe mitral regurgitation. During his workup for CABG and valve repair he was found to have cirrhosis secondary to HCV with hepatocellular carcinoma (HCC) by biopsy. After treatment for HCC the patient later developed recurrence due to needle track seeding. CASE DESCRIPTION/METHODS: After further imaging for his initial presentation of heart failure the patient underwent a CT guided fine needle aspiration and core needle biopsies of newly identified liver lesions in the left hepatic lobe (Figure 1). Pathology was consistent with HCC and the patient had no evidence of metastatic disease at that time. He was not deemed eligible for transplantation and was treated with transarterial chemoembolization (TACE). A surveillance MRI 7 months post-biopsy demonstrated a mass within the right rectus abdominus muscle which was located in the region of a prior biopsy tract (Figure 2). Given concerns for metastatic disease, the lesion was biopsied and histopathology was consistent with HCC. He was treated with cryoablation to the rectus abdominus muscle lesion and selective internal radiation therapy. The lesion was no longer visualized on follow-up imaging obtained four months later (Figure 3). DISCUSSION: Needle track seeding is a known complication with variable rates reported in the literature. More recent studies demonstrate a less than 1% rate of seeding when biopsy is performed alone.1,2 However, the rate is thought to be even lower in cases that use a coaxial biopsy system as was performed in this case. This is an important complication to consider as it may alter treatment; often disqualifying patients from liver transplantation or other curative procedures. For those who are being considered for liver transplantation diagnostic needle biopsies should be avoided if possible.Figure 1.: Axial contrast enhanced CT image in a 56 year old male showing CT guided percutaneous biopsy of a mass in the left hepatic lobe (circle).Figure 2.: Follow-up axial T1 post contrast MR images, 7 months later, showing a hyper-enhancing lesion in the right rectus abdominus muscle.Figure 3.: Axial T1 post contrast MR images of a 56-year-old male showing complete resolution of the soft tissue lesion following cryoablation. Residual tumor is noted in the left hepatic lobe.

PORTAL AND ARTERIAL REPERFUSION DURING LIVER TRANSPLANT: A COMPARISON BETWEEN THE SIMULTANEOUS AND SEQUENTIAL TECHNIQUES

Introduction: A critical step in the liver transplantation procedure is the reperfusion of the liver graft after being connected to the circulatory system of the receptor. There are two possible techniques for the reperfusion: it may occur immediately after the portal vein anastomosis has been completed, with revascularization of the graft with blood from the portal system first, and then with arterial blood after the completion of the arterial anastomosis, in what is usually referred to as the sequential technique; or the reperfusion can occur only after both portal and arterial anastomosis have been completed, in what is referred to as the simultaneous technique. There is significant debate in the literature on whether one of these techniques offer advantages over the other, with studies pointing to a reduction of biliary complications with use of the simultaneous technique, while other studies failed to show any improvement. We present an analysis of 100 liver transplants performed using each technique, consisting in the largest single-center study on this subject performed so far. Materials and Methods: We analyzed 200 liver transplants performed on a tertiary Brazilian hospital during the 2014 to 2017 period, with 100 transplants using the sequential technique being performed immediately before 100 transplants using the simultaneous technique. All procedures used whole liver grafts procured from cadaveric donors. Statistical analysis was performed using Yates corrected Pearson’s chi-square for qualitative parameters and t test for quantitative parameters. Results: There was a significant difference in blood products transfusion between the two groups, with a mean of 1.11 units in the sequential perfusion (SeP) group, as opposed to 0.59 in the simultaneous perfusion (SiP) group (p=0.02). There was also a statistically significant difference in total procedure time, with an average of 398 minutes in the SeP group vs. 368 in the SiP group (p=0.0001); total ischemia time, with an average of 421 minutes in the SeP group vs. 472 minutes in the SiP group (p=0.002); and receptor age, with a mean of 51.1 years in the SeP group vs. 54.3 in the SiP group (p=0.03). No difference was found in mortality or biliary stenosis between the two groups. Discussion: While there was an increase in total ischemia time associated with SiP, due to the additional time in completing the arterial anastomosis before reperfusion, there was no negative impact in patient mortality or morbidity. Reduction in total operative time and intraoperative transfusion may be associated with quicker hemostasis and liver function in SiP. Conclusion: The use of the simultaneous reperfusion technique in liver transplant, while having no direct impact on patient mortality, may decrease total procedure time and need for intraoperative blood transfusion. The expected increase in total ischemia time with the use of the simultaneous technique does not appear to increase patient morbidity or mortality.

BARRIERS IN ACCESS TO LIVER TRANSPLANTATION FOR ETHNIC MINORITY CHILDREN IN THE UNITED STATES DO NOT TRANSLATE INTO INFERIOR OUTCOMES

Purpose: Disparities in children undergoing liver transplantation (LT) exist and have been attributed to a combination of racial and socioeconomic circumstances. We sought to evaluate the influence of those barriers in access to LT on graft and patient survival. Methodology: We evaluated data from the U.S. Scientific Registry of Transplant Recipients (SRTR) of all pediatric (<18 years old) LT recipients from 1999 to 2014 and compared outcomes by race or ethnicity: Hispanic, non-Hispanic White (NHW), and non-Hispanic Blacks (NHB). We assessed 1- and 5-year patient survival (PS) and death-censored graft survival (DCGS). Characteristics controlled for included: living or deceased donor, brain- or cardiac-death donor (DCD), graft type (whole, partial, split), recipient age, BMI, primary disease, PELD score, re-transplant status, graft rejection, functional status, and cold ischemia time (CIT). Cox regression analysis was used with an alpha level of 0.05. Results: During the 15-year period, 8,331 (4,876 NHW, 1,522 NHB, and 1,933 Hispanic) pediatric LT procedures were performed in the U.S. Hispanic children were listed and transplanted at a significantly younger age (4.4, 4.8, respectively) than NHW (5.2, 5.6; p<0.001) and NHB children (5.1, 5.5; p<0.001). Compared to NHW (15.3%) and NHB (20.3%), there was a greater proportion of Hispanic children requiring total functional assistance (23.7%; p<0.001) at LT. Additionally, NHB and Hispanic children had exception points approved with lower frequency than NHW (p=0.036). Compared to NHW (14.2%), NHB (7.5%) and Hispanic (11.5%) children were less likely to have a living donor (p<0.001). NHB were more likely to receive a whole deceased donor graft (69.4%) than NHW or Hispanic children (63.4% and 59.6%, respectively; p<0.001). However, Hispanic children were more likely to receive a split deceased donor graft (19.8% for Hispanics, 12.9% for NHW, 14.7% for NHB; p<0.001). Listing PELD was higher for Hispanics (21.1±11.3) and NHB (20.4±10.7), compared to NHW (20.0±10.8; p=0.023). One-year PS for NHW, NHB, and Hispanics was 82.9%, 83.2%, and 83.1%, respectively; one-year DCGS was 82.8%, 83.1%, and 83.0%, respectively. Five-year PS for NHW, NHB, and Hispanics was 60.6%, 58.5%, and 57.9%, respectively; five-year DCGS was 60.6%, 58.5%, and 57.9%, respectively. None of these was significantly different in any two-way comparison.Multivariate analysis of one-year graft loss showed that older recipient age (HR 0.962, 95% CI 0.943-0.982) was protective while re-transplant status (1.554, 1.180-2.048) and the need for functional assistance (3.079, 2.307-4.109) were predictive of graft loss. Conclusion: Barriers exist for minority children to navigate the LT listing process. However, once transplanted, Hispanic and NHB children outcomes are comparable to NHW. Further research is necessary to understand and ease barriers in accessing LT for minority children.

IMPACT OF ROUTINE USE OF ABDOMINAL DRAINS ON THE DIAGNOSIS, MANAGEMENT AND OUTCOMES OF LIVER TRANSPLANT COMPLICATIONS

Introduction: The routine placement of abdominal drains at the end of the liver transplantation procedure, with one extremity inside the abdominal cavity, close to the liver graft and the anastomosis, and the other one placed on an external closed system, is a common practice in many liver transplantation centers. The rationale for the placement of the abdominal drains is the belief that, in the occurance of surgical complications, such as bleeding or formation of a biliary fistula, the drain will allow for the early diagnosis of that complication, and in some cases may be helpful in the treatment by preventing the accumulation of fluids in the abdominal caviity. However, the placement of abdominal drains can have a negative impact on the outcome of the procedure, either by causing the loss of large amounts of ascitic fluid and worsening electrolyte disturbances, or by increasing the risk of surgical site infections as described by some authors. We have performed an analysis of the impact of the placement of abdominal drains in the liver transplants done in one tertiary center. Materials and Methods: We have reviewed the medical records of 388 liver transplant patients in a single Brazilian hospital, in the period from 2012 to 2019. In the period from 2012 to 2015, drains were routinely placed in all patients. From 2015 onwards, drains were not placed in any patients. Statistical analysis was performed using Yates corrected Pearson’s chi-square for qualitative parameters and t test for quantitative parameters. Results: Of the 388 patients in the study, abdominal drains (AD) were placed on 162 (42%) of patients, while 226 (58%) used no abdominal drain (NAD). There were 21 cases of significant surgical complication in all patients: 16 cases of bleeding, being 5 in the AD group and 11 in the NAD group (p=0.38); and 5 cases of biliary fistula, being 1 in the AD group and 4 in the NAD group (p=0.32). The time for diagnosis and surgical intervention was not statistically different between the two groups, with a mean of 5 days in the NAD group and 2.2 days in the AD group suffering from bleeding (p=0.1); and a mean of 18.75 days in the NAD and 42 days in the AD group suffering from biliary fistula. Mortality was also not significantly different between groups, with 1 case in each group suffering from bleeding (p=0.54) and one case in the NAD suffering from biliary fistula. Discussion: The use of abdominal drains did not significantly reduce the time for diagnosis and intervention in patients suffering from post-operative bleeding or biliary fistula. It also had no impact on the mortalirty of patients suffering from these complications. Conclusions: The use of abdominal drains had no significant impact on the diagnosis, management and outcomes of surgical complications in liver transplant patients. Considering the complications associated with drain placement in other studies, routine placement of abdominal drains in this context may be questioned.