Journal Article Multicenter Study Ppublish
PubMed: 42789422 DOI: 10.1093/bjsopen/zrag154
Benchmarking paediatric living donor liver transplantation for establishing standards to expand access and save lives: retrospective global cohort study.
BJS Open 10(5)
Authors: Zhihao Li, Omid Madadi-Sanjani, Yuan Liu, Dimitri A Raptis, Vasanthakumar Gunasekaran, Ashwin Rammohan, Seisuke Sakamoto, Hajime Uchida, Piotr Kaliciński, Marek Stefanowicz, Nicolas Goldaracena, Cornelius J van Beekum, Felix J Krendl, Itsuko Chih-Yi Chen, Bryanna N Domenick, Alfred Kow, Kaihang Wang, Yuji Soejima, Katryn N Furuya, George V Mazariegos, Vidyadhar Padmakar Mali, Stephen C Dunn, Kim M Olthoff, Elizabeth B Rand, Ian Leipnitz, Chao-Long Chen, Deniz Balci, Elvan Onur Kirimker, Silvio Nadalin, Stefan Schneeberger, Debra L Sudan, Moritz Schmelzle, Uta Herden, Lutz Fischer, Blayne A Sayed, Vicky L Ng, Grzegorz Kowalewski, Mureo Kasahara, Mohamed Rela, Dieter C Broering, Qiang Xia, Pierre-Alain Clavien
Affiliations
- Department of Surgery and Transplantation, University of Zurich, Zurich, Switzerland.
- Department of Visceral Transplantation, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
- Department of Liver Surgery, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Organ Transplant Centre of Excellence, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
- Institue of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, India.
- Organ Transplantation Centre, National Centre for Child Health and Development (NCCHD), Tokyo, Japan.
- Department of Paediatric Surgery and Organ Transplantation, The Children's Memorial Health Institute, Warsaw, Poland.
- Department of Surgery, Division of Abdominal Transplant Surgery, University Health Network, Toronto, Ontario, Canada.
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany.
- Department of Visceral, Transplant and Thoracic Surgery, Centre for Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria.
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
- Department of Paediatric Surgery, National University Hospital, Singapore.
- University of Zurich, Zurich, Switzerland.
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Paediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan.
- Department of Paediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA.
- Hillman Centre for Paediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.
- Department of Solid Organ Transplantation, Alfred I. DuPont Hospital for Children, Wilmington, Delaware, USA.
- Department of Surgery, Penn Transplant Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
- Liver Transplant Unit, University of Auckland, Auckland, New Zealand.
- Department of General Surgery, Bahçeşehir University Faculty of Medicine, İstanbul, Turkey.
- Department of General Surgery, Ankara University Faculty of Medicine, Ankara, Turkey.
- Department of General Visceral and Transplant Surgery, Eberhard Karls University of Tübingen, Tübingen, Germany.
- Division of Abdominal Transplantation, Department of Surgery, Duke University Medical Centre, Durham, North Carolina, USA.
- Division of Gastroenterology, Hepatology and Nutrition, Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, Ontario, Canada.
- Wyss Zurich Translational Centre, ETH Zurich and University of Zurich, Zurich, Switzerland.
Abstract
BACKGROUND
Paediatric liver transplantation increasingly incorporates technical variant grafts including living donor liver transplantation (LDLT) to address donor shortages. However, the technical complexity of LDLT and regional outcome variations remain challenging. In settings with such variation and ongoing debate, standardized benchmarks may guide decision-making for broader implementation. This study establishes benchmark cut-off values for paediatric LDLT outcomes to provide a validated framework for quality assessment and safe programme expansion.
METHODS
An international analysis was conducted of paediatric patients who underwent LDLT at 19 centres between 2019 and 2023. Benchmark cut-off values were derived from 'ideal' patients at seven high-volume institutions, representing the best achievable results under optimal conditions. Surgical complications were graded using the Clavien-Madadi classification, compared against the standard Clavien-Dindo system for accuracy.
RESULTS
In all, 2665 patients were included, of which 1988 counted as ideal patients. The median recipient age was 10 (interquartile range (i.q.r.) 6-26) months with median weight of 8.0 (i.q.r. 6.6-11.9) kg. Biliary atresia was the most common diagnosis (68.8%), and most recipients (90.9%) received a left lateral segment graft. The 75th percentile of median centre values were used to define the following benchmark cut-off values: hepatic artery thrombosis ≤ 5%, bile leak ≤ 12%, biliary anastomotic stricture ≤ 6%, and 1-year graft loss or mortality ≤ 6%. Higher centre volume was associated with more selective patient inclusion and fewer major (particularly biliary) complications. An inverse correlation between case volume and failure-to-rescue rate highlighted the critical role of multidisciplinary perioperative management. The Clavien-Madadi classification proved superior to the Clavien-Dindo system, which overclassified grade III complications.
CONCLUSIONS
This study provides a framework to guide safe programme expansion, improve surgical quality, and reduce waitlist mortality.
MeSH
Liver Transplantation, Mortality, Surgical Procedures, Operative, Cohort Studies, Classification, Liver, Transplants, Benchmarking, Transplantation