Outcomes of normothermic machine perfusion of liver grafts in repeat liver transplantation (NAPLES initiative).

BACKGROUND: Retransplantation candidates are disadvantaged owing to lack of good-quality liver grafts. Strategies that can facilitate transplantation of suboptimal grafts into retransplant candidates require investigation. The aim was to determine whether late liver retransplantation can be performed safely with suboptimal grafts, following normothermic machine perfusion. METHODS: A prospectively enrolled group of patients who required liver retransplantation received a suboptimal graft preserved via normothermic machine perfusion. This group was compared with both historical and contemporaneous cohorts of patient who received grafts preserved by cold storage. The primary outcome was 6-month graft and patient survival. RESULTS: The normothermic machine perfusion group comprised 26 patients. The historical (cold storage 1) and contemporaneous (cold storage 2) groups comprised 31 and 25 patients respectively. The 6-month graft survival rate did not differ between groups (cold storage 1, 27 of 31, cold storage 2, 22 of 25; normothermic machine perfusion, 22 of 26; P = 0.934). This was despite the normothermic machine perfusion group having significantly more steatotic grafts (8 of 31, 7 of 25, and 14 of 26 respectively; P = 0.006) and grafts previously declined by at least one other transplant centre (5 of 31, 9 of 25, and 21 of 26; P < 0.001). CONCLUSION: In liver retransplantation, normothermic machine perfusion can safely expand graft options without compromising short-term outcomes.

Liver transplantation is a life-saving procedure for many different diseases. In the UK, one in 10 patients awaiting transplant have had a previous liver transplant. These retransplant operations are complex, and the general belief is that a good-quality donor liver graft is required for best outcomes. However, there is a significant shortage of good-quality organs for liver transplantation, so many patients awaiting retransplantation spend longer on the waiting list. This study investigated whether a new technology, called normothermic machine perfusion, could be used to preserve lower-quality donor livers and have successful outcomes for patients undergoing retransplantation. Traditionally, good-quality livers are preserved in an ice box and the study compared the outcomes of these two different approaches. The aim was to prove that normothermic machine perfusion improves access to transplantation for this group of patients, without compromising outcomes. A group of patients who underwent retransplantation and received a lesser-quality liver preserved with normothermic machine perfusion was compared with two groups of patients who had received a transplant with traditional ice-box preservation. The complications, graft, and patient survival of the former group was compared with those in the latter two groups who underwent liver retransplantation with better-quality liver grafts. The rate of survival and adverse surgical outcomes were comparable between the groups of patients who received a liver preserved via traditional ice-box preservation, and those who received a lesser-quality liver preserved via normothermic machine perfusion. Normothermic machine perfusion can potentially expand the number of suitable donor livers available for retransplant candidates.

The long-term quality of life following liver transplantation in a developing country with a free health care system.

Introduction: Developing countries with limited resources are yet to establish universal liver transplant (LT) services to cater to their population free of charge. In this unique setting, no data are published on the long-term Quality of life (QOL) of LT survivors. Objectives: Compare the long-term quality of life of post-liver transplant patients with a matching cohort of pretransplant cirrhotic patients and a matching non cirrhotic control group. Methods: Of the 45 liver transplants that were performed there were 24 patients who completed over 6 months of follow-up. Of these, 4 patients died (including one lost to follow-up) after six months. The remaining 20 post-transplant patients were the subjects for QOL assessment. One post-transplant recipient was matched with two pre-transplant cirrhotic patients and non-cirrhotic healthy control group. QOL was evaluated by the SF-36 questionnaire. Results and conclusions: The median age was 54 years (27-67) and 85% (n=17) were male. The median follow up was 24 months (6- 94 months). The median MELD score was 17 (11-22) and 75% (n=15) were due to cryptogenic cirrhosis. Post-operatively three (15%) developed graft rejection, five (25%) had infections and ten (50%) suffered drug related complications. 95% (n= 19) of the population had satisfactory drug compliance. The study population had significantly better QOL compared to control in all eight domains (p<0.05) including physical functioning (76% vs 52.7%), physical health (80% vs 7.9%), emotional problems (93% vs 17.1%), energy (77% vs 47%), emotional wellbeing (80% vs 61.1%), social functioning (86.9% vs 56.9%), pain (82% vs 47.5%) and general health (67.5% vs 37.5%). The study population had similar quality of life compared to the healthy control group with better-perceived emotional well-being. Conclusion: Long-term survivors after LT have significantly improved QOL in a setting with limited resources.

A novel structure for online surgical undergraduate teaching during the COVID-19 pandemic.

BACKGROUND: The Covid-19 pandemic necessitated the delivery of online higher education. Online learning is a novel experience for medical education in Sri Lanka. A novel approach to undergraduate surgical learning was taken up in an attempt to improve the interest amongst the students in clinical practice while maximizing the limited contact time. METHOD: Online learning activity was designed involving medical students from all stages and multi consultant panel discussions. The discussions were designed to cover each topic from basic sciences to high-level clinical management in an attempt to stimulate the student interest in clinical medicine. Online meeting platform with free to use basic plan and a social media platform were used in combination to communicate with the students. The student feedback was periodically assessed for individual topics as well as for general outcome. Lickert scales and numeric scales were used to acquire student agreement on the desired learning outcomes. RESULTS: A total of 1047 student responses for 7 questionnaires were analysed. During a 6-week period, 24 surgical topics were discussed with 51 contact hours. Eighty-seven per cent definitely agreed (highest agreement) with the statement 'students benefitted from the discussions'. Over 95% have either participated for all or most sessions. A majority of the respondents (83.4%) 'definitely agreed' that the discussions helped to improve their clinical sense. Of the total respondents, 79.3% definitely agreed that the discussions helped to build an interest in clinical medicine. Around 90% agreed that both exam-oriented and clinical practice-oriented topics were highly important and relevant. Most widely raised concerns were the poor Internet connectivity and limitation of access to the meeting platform. CONCLUSION: Online teaching with a novel structure is feasible and effective in a resource-limited setting. Students agree that it could improve clinical interest while meeting the expected learning outcomes.