Title
HOPE and Biliary Complications in Liver Transplantation: A 12-year single – center retrospective analysis
Authors
Prior Margherita1, Serenari Matteo1,3, Eusebi Leonardo Henry2,3, Stocco Alberto1,3, Iuvinale Mika 2, Di Noia Giulia2, Bruni Angelo2,3, Prosperi Enrico1,3, Fallani Guido1,3, Bonatti Chiara1,3, Laici Cristiana4, Barbara Giovanni 2,3, Ravaioli Matteo 2,3, and Cescon Matteo 2,3
1Hepatobiliary surgery and Transplant unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
2 Gastroenterology Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy.
3Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
4Postoperative and Abdominal Organ Transplant Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
Introduction
Biliary complications (BC) remain among the most challenging postoperative issues following liver transplantation (LT). Since 2018, our center introduced systematic use of hypothermic oxygenated perfusion (HOPE) for selected grafts, aiming to reduce ischemia–reperfusion injury, improve LT outcomes and recondition marginal grafts. We conducted a preliminary comparative analysis of LT recipients transplanted before and after the introduction of HOPE to evaluate its impact on the incidence, type, and management of BC, with particular attention to T-tube utilization and post-removal complications.
Methods
A retrospective analysis of 1128 patients undergone LT between 2012 and 2023 at Hepatobiliary and Transplant Surgery Unit of Policlinico Sant’Orsola di Bologna was performed. Patients were stratified into two periods: pre-HOPE (n=566) and post-HOPE (n=562). We explored patients’ demographic characteristics, biliary complication rates, use of ERCP or surgical revision, type of biliary anastomosis, T-tube placement, and complications following T-tube removal.
Results
In the second period HOPE was applied in 52,7 % of grafts, reflecting its routine adoption in clinical practice with significant shifts in biliary outcomes. The incidence of overall BC decreased in the post-HOPE era (19.1% vs. 14.8%, p<0.001), with a notable reduction in non-anastomotic strictures and leak-related complications. Use of T-tube increased significantly in the post-HOPE group (74.5% vs 50.9%, p<0.001) likely due to the preferential application of HOPE to more marginal grafts. Despite higher T-tube utilization, post-removal complications remained stable, showing only a non-significant increase (29.8% vs. 37.6%, p=0.051), while T-tube-related hospital readmissions did not differ between periods. The indications for ERCP after LT differed significantly between the two periods (p<0.001). Biliary leaks became markedly more frequent after 2019 (42.4% vs. 6.7%), while anastomotic strictures decreased (36.4% vs. 64.4%).
Conclusions
The introduction of HOPE in our center was associated with improved biliary outcomes and a reduction in the overall BC. Our findings support the integration of HOPE into LT practice and highlight the importance of a multimodal, era-specific evaluation of biliary complications. Further prospective studies are needed to isolate the specific protective effect of HOPE from concurrent surgical and clinical innovations.
