Dutkowski, Philipp MD*; Oberkofler, Christian E. MD*; Slankamenac, Ksenija MC*; Puhan, Milo A. MD‡; Schadde, Erik MD*; Müllhaupt, Beat MD†; Geier, Andreas MD†; Clavien, Pierre A. MD, PhD*
Objectives: To design a new score on risk assessment for orthotopic liver transplantation (OLT) based on both donor and recipient parameters.
Background: The balance of waiting list mortality and posttransplant outcome remains a difficult task in the era of the model for end-stage liver disease (MELD).
Methods: Using the United Network for Organ Sharing database, a risk analysis was performed in adult recipients of OLT in the United States of America between 2002 and 2010 (n = 37,255). Living donor-, partial-, or combined-, and donation after cardiac death liver transplants were excluded. Next, a risk score was calculated (balance of risk score, BAR score) on the basis of logistic regression factors, and validated using our own OLT database (n = 233). Finally, the new score was compared with other prediction systems including donor risk index, survival outcome following liver transplantation, donor-age combined with MELD, and MELD score alone.
Results: Six strongest predictors of posttransplant survival were identified: recipient MELD score, cold ischemia time, recipient age, donor age, previous OLT, and life support dependence prior to transplant. The new balance of risk score stratified recipients best in terms of patient survival in the United Network for Organ Sharing data, as in our European population.
Conclusions: The BAR system provides a new, simple and reliable tool to detect unfavorable combinations of donor and recipient factors, and is readily available before decision making of accepting or not an organ for a specific recipient. This score may offer great potential for better justice and utility, as it revealed to be superior to recent developed other prediction scores.
Farges, Olivier MD, PhD*; Fuks, David MD†; Boleslawski, Emmanuel MD‡; Le Treut, Yves-Patrice MD§; Castaing, Denis MD¶; Laurent, Alexis MD‖; Ducerf, Christian MD**; Rivoire, Michel MD††; Bachellier, Philippe MD‡‡; Chiche, Laurence MD§§; Nuzzo, Gennaro MD¶¶; Regimbeau, Jean Marc MD†
Objective: Define the optimal surgical margin in patients undergoing surgery for intrahepatic cholangiocarcinoma (IHCC).
Background Data: Surgery is the most effective treatment for IHCC. However, the influence of R1 resection on outcome is controversial and that of margin width has not been evaluated.
Methods: We studied 212 patients undergoing curative resection of mass-forming–type IHCC. The respective influences on survival of resection status (R0 vs R1), surgical margin width, pTNM stage, and the latter's components were evaluated.
Results: Incidence of R1 resection was 24%. Overall, R1 resection was not an independent predictor of survival [odds ratio (OR) 1.2 (0.7–2.1)] in contrast to the pTNM stage [OR 2.10 (1.2–3.5)]. In the 78 pN+ patients, survival was similar after R0 and R1 resections (median: 18 vs 13 months, respectively, P = 0.1). In the 134 pN0 patients, R1 resection was an independent predictor of poor survival [OR 9.6 (4.5–20.4)], as was the presence of satellite nodules [OR 1.9 (1.1–3.2)]. In the 116 pN0 patients with R0 resections, median survival was correlated with margin width (≤1 mm: 15 months; 2–4 mm: 36 months; 5–9 mm: 57 month; ≥10 mm: 64 month, P < 0.001) and a margin >5 mm was an independent predictor of survival [OR 2.22 (1.59–3.09)].
Conclusion: Patients undergoing surgery for IHCC are at high risk of R1 resections. In pN0 patients, R1 resection is the strongest independent predictor of poor outcome and a margin of at least 5 mm should be created. The survival benefits of resection in pN+ patients and R1 resection in general are very low.