BACKGROUND Biliary reconstruction is the most technically demanding step in living donor liver transplantation (LDLT), yet how a single surgeon's technique matures in the early career, and how this relates to clinical outcomes, remains incompletely characterized. This study evaluated whether the stepwise evolution of surgical technique was associated with a lower anastomotic biliary stricture (BS) rate. MATERIAL AND METHODS We retrospectively analyzed 382 consecutive right-lobe LDLTs with single-surgeon duct-to-duct biliary anastomosis performed between April 2020 and April 2024. Cases were grouped into 3 equal, consecutive time intervals (approximately 16 months each), and cumulative sum (CUSUM) analysis was applied to the learning trajectory. Independent risk factors for BS were identified by multivariable logistic regression, with separate models for surgical period and post-transition-point status. RESULTS BS rates decreased across periods from 14.4% to 10.1% to 5.1% (P trend=0.016). CUSUM identified a primary transition at case 33, ending the initial trial-and-error phase and coinciding with adoption of well-vascularized distal recipient duct selection, and a secondary inflection at case 210 coinciding with eversion-overlap anastomosis with hilar plate anchoring. Portal vein stenting (OR 6.515, P=0.004) and ABO-incompatible transplantation (OR 2.462, P=0.016) were independent risk factors. After adjustment, surgical period (OR 0.596, P=0.027) and post-case-33 status (OR 0.291, P=0.010) remained associated with lower BS odds. CONCLUSIONS In this single-surgeon cohort, the stepwise evolution of surgical technique was associated with a progressive reduction in BS rates, alongside the cumulative standardization of fundamental principles, but a concurrently evolving case mix precludes attribution to technique alone.
BACKGROUND Acute-on-chronic liver failure (ACLF) is associated with multiorgan failure and high short-term mortality. Liver transplantation (LT) can be lifesaving, but commonly used pretransplant severity scores were not developed to predict post-transplant mortality. This study compared AARC, CLIF-C ACLF, and MELD-Na for 90-day mortality after LT. MATERIAL AND METHODS This single-center observational cohort study included 78 consecutive patients aged 16 years or older with EASL-CLIF ACLF who underwent LT at the 108 Military Central Hospital between January 2022 and June 2025. All 3 scores were independently recalculated from a common pretransplant assessment. The primary outcome was 90-day all-cause mortality, and the primary score comparison was non-directional. Discrimination was assessed using AUROCs with stratified percentile-bootstrap confidence intervals and paired DeLong comparisons with Holm adjustment. Separate Firth logistic and Cox models evaluated associations per 1-standard-deviation increase. RESULTS HBV-related liver disease accounted for 62.8% of the cohort, and 89.7% underwent living-donor LT. Fourteen patients (17.9%) died within 90 days. CLIF-C ACLF had the highest numerical AUROC (0.755; 95% CI, 0.562-0.917), followed by MELD-Na (0.714; 0.550-0.854) and AARC (0.654; 0.491-0.799); no pairwise difference remained significant after Holm adjustment. A 1-standard-deviation increase in CLIF-C ACLF (11.05 points) and MELD-Na (6.17 points) was associated with higher 90-day mortality, whereas AARC was not. Sensitivity analyses produced similar findings. CONCLUSIONS CLIF-C ACLF showed the strongest numerical prognostic performance, but statistically significant superiority was not established. These scores should complement multidisciplinary transplant assessment.
