Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland.
The Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, TN, India.
Ann Surg. 2023 Nov 1;278(5):798-806. doi: 10.1097/SLA.0000000000006038. Epub 2023 Jul 21.
To define benchmark values for adult-to-adult living-donor liver transplantation (LDLT).
LDLT utilizes living-donor hemiliver grafts to expand the donor pool and reduce waitlist mortality. Although references have been established for donor hepatectomy, no such information exists for recipients to enable conclusive quality and comparative assessments.
Patients undergoing LDLT were analyzed in 15 high-volume centers (≥10 cases/year) from 3 continents over 5 years (2016-2020), with a minimum follow-up of 1 year. Benchmark criteria included a Model for End-stage Liver Disease ≤20, no portal vein thrombosis, no previous major abdominal surgery, no renal replacement therapy, no acute liver failure, and no intensive care unit admission. Benchmark cutoffs were derived from the 75th percentile of all centers' medians.
Of 3636 patients, 1864 (51%) qualified as benchmark cases. Benchmark cutoffs, including posttransplant dialysis (≤4%), primary nonfunction (≤0.9%), nonanastomotic strictures (≤0.2%), graft loss (≤7.7%), and redo-liver transplantation (LT) (≤3.6%), at 1-year were below the deceased donor LT benchmarks. Bile leak (≤12.4%), hepatic artery thrombosis (≤5.1%), and Comprehensive Complication Index (CCI ® ) (≤56) were above the deceased donor LT benchmarks, whereas mortality (≤9.1%) was comparable. The right hemiliver graft, compared with the left, was associated with a lower CCI ® score (34 vs 21, P < 0.001). Preservation of the middle hepatic vein with the right hemiliver graft had no impact neither on the recipient nor on the donor outcome. Asian centers outperformed other centers with CCI ® score (21 vs 47, P < 0.001), graft loss (3.0% vs 6.5%, P = 0.002), and redo-LT rates (1.0% vs 2.5%, P = 0.029). In contrast, non-benchmark low-volume centers displayed inferior outcomes, such as bile leak (15.2%), hepatic artery thrombosis (15.2%), or redo-LT (6.5%).
Benchmark LDLT offers a valuable alternative to reduce waitlist mortality. Exchange of expertise, public awareness, and centralization policy are, however, mandatory to achieve benchmark outcomes worldwide.
定义成人对成人活体肝移植（LDLT）的基准值。
LDLT 利用活体供肝半肝移植来扩大供者库并降低等待名单上的死亡率。尽管已经为供肝切除术制定了参考标准，但对于受者来说，没有这样的信息来进行明确的质量和比较评估。
对来自三大洲的 15 个高容量中心（≥10 例/年）在 5 年内（2016-2020 年）接受 LDLT 的患者进行了分析，随访时间至少为 1 年。基准标准包括终末期肝病模型（MELD）≤20，无门静脉血栓形成，无先前的主要腹部手术，无肾脏替代治疗，无急性肝衰竭，无重症监护病房入住。基准截止值来自所有中心中位数的第 75 百分位数。
在 3636 名患者中，有 1864 名（51%）符合基准病例标准。基准截止值，包括移植后透析（≤4%）、原发性无功能（≤0.9%）、非吻合口狭窄（≤0.2%）、移植物丢失（≤7.7%）和再次肝移植（LT）（≤3.6%），在 1 年时低于已故供体 LT 基准值。胆漏（≤12.4%）、肝动脉血栓形成（≤5.1%）和综合并发症指数（CCI ® ）（≤56）高于已故供体 LT 基准值，而死亡率（≤9.1%）则相当。与左半肝相比，右半肝供肝与较低的 CCI ® 评分相关（34 与 21，P <0.001）。保留右半肝的中肝静脉对受者和供者的结果均无影响。亚洲中心的 CCI ® 评分（21 与 47，P <0.001）、移植物丢失（3.0%与 6.5%，P = 0.002）和再次 LT 率（1.0%与 2.5%，P = 0.029）均优于其他中心。相比之下，非基准低容量中心的结果较差，如胆漏（15.2%）、肝动脉血栓形成（15.2%）或再次 LT（6.5%）。
基准 LDLT 为降低等待名单上的死亡率提供了一个有价值的选择。然而，要在全球范围内实现基准结果，需要交流专业知识、提高公众意识和实施集中化政策。
