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Defining Benchmarks in Liver Transplantation

A Multicenter Outcome Analysis Determining Best Achievable Results

Muller, Xavier MD*; Marcon, Francesca MD; Sapisochin, Gonzalo MD; Marquez, Max MD; Dondero, Federica MD§; Rayar, Michel MD; Doyle, Majella M. B. MD||; Callans, Lauren**; Li, Jun MD††; Nowak, Greg MD‡‡; Allard, Marc-Antoine MD§§; Jochmans, Ina MD, PhD¶¶; Jacskon, Kyle MD||||; Beltrame, Magali Chahdi MD***; van Reeven, Marjolein MD†††; Iesari, Samuele MD‡‡‡; Cucchetti, Alessandro MD§§§; Sharma, Hemant MD¶¶¶,||||||; Staiger, Roxane D. MD*; Raptis, Dimitri A. MD, PhD*; Petrowsky, Henrik MD*; de Oliveira, Michelle MD*; Hernandez-Alejandro, Roberto MD¶¶¶,||||||; Pinna, Antonio D. MD§§§; Lerut, Jan MD, PhD‡‡‡; Polak, Wojciech G. MD, PhD†††; de Santibañes, Eduardo MD***; de Santibañes, Martín MD***; Cameron, Andrew M. MD, PhD||||; Pirenne, Jacques MD, PhD¶¶; Cherqui, Daniel MD§§; Adam, René A. MD, PhD§§; Ericzon, Bö-Göran MD, PhD‡‡; Nashan, Bjoern MD, PhD††; Olthoff, Kim MD**; Shaked, Avi MD**; Chapman, William C. MD||; Boudjema, Karim MD; Soubrane, Olivier MD, PhD§; Paugam-Burtz, Catherine MD, PhD§; Greig, Paul D. MD; Grant, David R. MD; Carvalheiro, Amanda MD; Muiesan, Paolo MD; Dutkowski, Philipp MD*; Puhan, Milo MD, PhD****; Clavien, Pierre-Alain MD, PhD*

doi: 10.1097/SLA.0000000000002477

This multicentric study of 17 high-volume centers presents 12 benchmark values for liver transplantation. Those values, mostly targeting markers of morbidity, were gathered from 2024 “low risk” cases, and may serve as reference to assess outcome of single or any groups of patients.

Objective: To propose benchmark outcome values in liver transplantation, serving as reference for assessing individual patients or any other patient groups.

Background: Best achievable results in liver transplantation, that is, benchmarks, are unknown. Consequently, outcome comparisons within or across centers over time remain speculative.

Methods: Out of 7492 liver transplantation performed in 17 international centers from 3 continents, we identified 2024 low risk adult cases with a laboratory model for end-stage liver disease score ≤20 points, a balance of risk score ≤9, and receiving a primary graft by donation after brain death. We chose clinically relevant endpoints covering intra- and postoperative course, with a focus on complications graded by severity including the complication comprehensive index (CCI®). Respective benchmarks were derived from the median value in each center, and the 75 percentile was considered the benchmark cutoff.

Results: Benchmark cases represented 8% to 49% of cases per center. One-year patient-survival was 91.6% with 3.5% retransplantations. Eighty-two percent of patients developed at least 1 complication during 1-year follow-up. Biliary complications occurred in one-fifth of the patients up to 6 months after surgery. Benchmark cutoffs were ≤4 days for ICU stay, ≤18 days for hospital stay, ≤59% for patients with severe complications (≥ Grade III) and ≤42.1 for 1-year CCI®. Comparisons with the next higher risk group (model for end stage liver disease 21–30) disclosed an increase in morbidity but within benchmark cutoffs for most, but not all indicators, while in patients receiving a second graft from 1 center (n = 50) outcome values were all outside of benchmark values.

Conclusions: Despite excellent 1-year survival, morbidity in benchmark cases remains high with half of patients developing severe complications during 1-year follow-up. Benchmark cutoffs targeting morbidity parameters offer a valid tool to assess higher risk groups.

*Department of Surgery and Transplantation, Swiss HPB Center Zurich, University Hospital Zurich, Zurich, Switzerland

Department of HBP Surgery and Transplantation, Queen Elizabeth Hospital and Birmingham Children's Hospital, Birmingham, UK

Department of Surgery, Abdominal Transplant and HPB Surgical Oncology, Toronto General Hospital, University of Toronto, Toronto, ON, Canada

§Department of Surgery and Transplantation, Hôpital Beaujon, Clichy, France

Department of HBP Surgery and Transplantation, University Hospital Rennes, Rennes, France

||Division of General Surgery and Section of Abdominal Transplantation, Washington University School of Medicine, St. Louis, MO

**Division of Transplantation, University of Pennsylvania, Philadelphia, PA

††Department of Hepatobiliary Surgery and Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

‡‡Division of Transplantation Surgery, CLINTEC Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden

§§Department of Surgery, The Hepatobilairy Center, Paul Brousse Hospital, University Paris Sud, Villejuif, France

¶¶Abdominal Transplant Surgery, KU Leuven, University Hospitals Leuven, Leuven, Belgium

||||Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD

***Division of HBP Surgery, Department of Surgery, Liver Transplant Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina

†††Department of Surgery and Transplantation, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands

‡‡‡Department of Abdominal and Transplant Surgery, University Hospital St. Luc, Brussels, Belgium

§§§Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy

¶¶¶Division of Transplantation, University of Rochester Medical Center, New York, NY

||||||Department of Surgery, Western University, London, ON, Canada

****Department of Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.

Reprints: Pierre-Alain Clavien, MD, PhD, Department of Surgery and Transplantation, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland. E-mail:

CCI® refers to registered trademark from the University of Zurich, Zurich, Switzerland.

The authors report no conflicts of interest.

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