Tracheostomy in the Management of Pre-Operative Respiratory Failure in Liver Transplant Candidates

Background: Chronic respiratory failure in end-stage liver disease (ESLD) is associated with a high mortality and has been traditionally considered a contraindication for orthotopic liver transplantation (OLT) and the outcomes in patients undergoing pre-operative tracheostomy have not been well studied.In order to better understand clinical consequences of pre-operative tracheostomy in OLT recipients, we hypothesized that, in carefully selected candidates, tracheostomy should not be an absolute contraindication for OLT. Methods:We analyzed preoperative characteristics and postoperative outcomes of pre-OLT tracheostomized patients at a single high-volume liver transplant center from 2015 to 2021 and compared them to OLT recipients requiring post-operative tracheostomy and to the overall cohort of adult OLT recipients without perioperative tracheostomy.1.3.Results: Duration of tracheostomy prior to transplant was 50 days (IQR = 60), total duration of tracheostomy was 121 days (IQR = 35), and all patients were ultimately decannulated.Excluding one patient currently alive 15 months post-transplant, one-year and twoyear survival for pre-OLT tracheostomized patients was 100% and 80%, respectively.In comparison to survival of pre-OLT tracheostomized patients, those requiring tracheostomy post-OLT had oneyear and two-year unadjusted survival of 51.3% and 48.8% respec-tively, while the overall unadjusted one and two-year survival among all 710 patients was 83.0% and 81.9%. Conclusions:Although chronic respiratory failure requiring tracheostomy is often considered a contraindication to OLT, our data suggests that, in a carefully selected population of OLT candidates, tracheostomy should not be considered a barrier to transplant and pre-OLT tracheostomized patients may actually demonstrate positive outcomes post-transplant.