Liver transplantation (LT) is a complex procedure that is occasionally associated with a challenging postoperative course. This requires an intricate postoperative management coupled with raised awareness of potential pitfalls and swift intervention to ensure a successful patient outcome. Striking the right balance between operative intervention and conservative treatment is an art that relies on the experience of the team and an appreciation of the short- and long-term implications of each complication. During the past decade, LT outcomes have continued to improve, despite significant changes in the demographics of LT recipients and the donor population.1 There remains, however, an early attrition rate that, despite improvements in surgical strategy and postoperative care, reflects the detrimental impact of the perioperative surgical issues and highlights the need to resolve these early complications that would otherwise impair the patient outcomes and increase the healthcare costs associated with the transplant. As such, continuous reevaluation and regular audits to identify areas for quality improvement are essential to good clinical practice and should be routine in every center. In the article by Deyrat et al,2 the results of such an audit in a leading European center confirm that early unexpected reoperations (EUReop) remain a common problem affecting 17% of LT recipients and are driven by bleeding, followed by arterial complications and wound disruptions. Although these findings are not unexpected nor new, they highlight yet again the critical role of meticulous surgical technique with attention to the wider operative field, including the digestive arteries, the diaphragm, and the perihepatic spaces, and the critical role of prompt identification and resolution of these complications. A detailed analysis confirmed known recipient factors (eg, care in the intensive care unit or hospitalization at the time of LT, retransplantation), donor factors (eg, split graft), and perioperative issues (eg, portal vein thrombosis PVT, increased need for red blood cell transfusion) that impact EUReop. This constellation of factors should lead by default to a more proactive approach, as procrastination (eg, managing biliary complications) or delayed interventions have serious unintended consequences for the patients, with late EUReop (defined as later than 1 wk from index surgery) being associated with worse survival compared with early EUReop. The impact is sobering, as EUReop leads not only to significantly worse 90-d survival but also a long-lasting impact with worse medium- and long-term survival for these patients. These analyses showcase the complex heterogeneity of LT and its complications, as EUReop is associated with decreased survival, but not necessarily every risk factor for EUReop affects patient survival. PVT is identified as a significant perioperative risk factor for EUReop, in line with previous studies.3 Although the authors use a decision-driven classification system for PVT,4 they do not evaluate the impact of different PVT subgroups on the rate of early unplanned reoperation. In our experience, previously recanalized PVT poses significantly fewer surgical challenges compared with chronic, manifest PVT. Furthermore, other complications of portal hypertension, such as large spontaneous splenorenal shunts, can also present considerable difficulties.5 Including these variables in the risk factor analysis for EUReop would strengthen the study. A more detailed explanation of the authors’ institutional management of PVT, along with more specific information on institutional practices and intersurgeon variations in general, and how these may influence EUReop rates, would provide valuable practical guidance for clinicians elsewhere. Deyrat et al also describe that improved practice over the eras led to an impressive reduction in the failure-to-rescue rate from 48% to 20%. Rather disappointingly, these improvements did not translate into lower 90-d mortality, raising the question of whether the retrospective nature of the study failed to capture the shift toward minimally invasive procedures in patients with the most severe complications post LT who may not be in an optimal condition for reoperations. A more granular analysis of the factors contributing to the decrease in failure-to-rescue would be a valuable learning point for other centers. Whilst this is a retrospective study spanning 11 y, it did not investigate the impact of machine perfusion (MP) as a mitigating strategy on EUReop and associated mortality. Several studies have shown that MP decreases the risk of complications and improves outcomes in LT.6,7 MP not only targets donor-related factors identified as risk factors in this analysis but also offers the opportunity to improve logistics8 and reduce nighttime surgery—a factor that may have had a major contribution to the reported findings.9 Despite the impressive volume of cases during the study timeframe, this remains a single-center analysis and, as such, it failed to achieve sufficient statistical power for certain complications. A better understanding requires larger analyses at the multicenter level, which can be greatly facilitated by the unique European LT registry. This study is a stark reminder of the complexity of LT surgery, the constellation of risk factors, and the need for timely and effective interventions to ensure good long-term outcomes. In an era of patient-centered care, we owe it to our patients not only to be transparent about the risks of surgery but also to use any means necessary to provide the best start in the 1 operation that will save their lives.
Vidgren et al. (Fri,) studied this question.