BACKGROUND:Perihilar cholangiocarcinoma (pCCA) is a rare malignancy originating from the bile duct bifurcation which is often diagnosed in an advanced stage. At presentation, most patients present with jaundice requiring biliary drainage. Palliative chemotherapy (pCTx) has a positive impact on survival and quality of life. The primary aim of this study was to investigate the impact of biliary drainage on pCTx initiation in patients with non-resected pCCA. METHODS:Individual patient data from all Dutch patients diagnosed with non-resected pCCA between 2015 and 2020 were retrieved from the Netherlands Cancer Registry. Primary outcome were factors associated with initiation of pCTx, analysed by multivariable competing risk regression analysis. RESULTS:A total of 1265 patients were included, of whom 242 patients (19.1%) received pCTx after a median interval of 72 days [IQR 43-110 days] after initial presentation. Patients who underwent biliary drainage did not receive pCTx more often. If performed, drainage at a referral hospital (HR:0.65, 95%CI: 0.42-0.99), ≥3 drainage procedures performed (HR:0.53, 95%CI: 0.32-0.88), and drainage performed ≥14 days after presentation (HR:0.70, 95%CI: 0.49-0.99) were associated with no pCTx. Median overall survival for those who received pCTx and those who did not was 12.8 months [95%CI: 11.7-14.2] and 2.7 months [95%CI: 2.4-3.1]. CONCLUSION:The need for biliary drainage did not affect the initiation of pCTx. When indicated, biliary drainage should be performed as quick as possible in an academic center to improve the rate of patients receiving pCTx.

BACKGROUND:Gallbladder polyps are seen in up to 7% of adults and carry a low malignancy risk. Guidelines on indication for surgery and follow-up remain controversial because of regional differences in the development of malignancy. This study compares European practice guidelines for gallbladder polyps and assesses the percentage of patients in whom cholecystectomy was indicated according to the guidelines with a true adenoma postoperatively. METHODS:Dutch patients with active follow-up or surgery for gallbladder polyps between 2018 and 2020 in 26 participating centres were included. Data on demographics, imaging characteristics, surgery and histopathology were assessed. Indications for cholecystectomy were examined for all patients comparing 2017 and 2022 European guidelines. RESULTS:A cohort of 302 patients was included. Patients in follow-up underwent imaging three times (median) and were followed up during a median of 23.2 months (IQR 10.9-47.4). In total, 88 patients (29%) underwent cholecystectomy after a median period of 23 months and a median of two instances of imaging. In 71 of 88 patients (81%) who underwent cholecystectomy, the gallbladder polyps was a valid indication for cholecystectomy according to 2017 guidelines, compared to 68 of 88 (77%) according to 2022 guidelines. The difference only occurred due to age as a risk factor which changed from 50 to 60 years of age. Of 71 operated patients, non-neoplastic polyps were found in 49 (69%), no gallbladder wall abnormality was found in 23 (32%). An adenoma was found in six patients (9%), of which three had low grade dysplasia and one had high grade dysplasia. DISCUSSION:Despite revision of guidelines in 2022, a significant number of patients still undergo follow-up and cholecystectomy for non-neoplastic gallbladder polyps, indicating the need for a more comprehensive risk assessment algorithm in the management of gallbladder polyps.

BACKGROUND:Major liver resection is frequently performed for primary and secondary liver tumors. However, 90-day mortality rates can exceed 10% in high-risk patients. This study aimed to develop a preoperative risk score for postoperative mortality after major liver resection. METHODS:All major liver resections between 2014 and 2019 in 2 Dutch tertiary referral centers were identified. A validation cohort consisted of all consecutive patients who underwent a major liver resection in the nationwide Dutch Hepato Biliary Audit from 2014 to 2020. Multivariate logistic regression was used to identify prognostic factors and develop a mortality risk score. RESULTS:Major liver resection was performed in 513 patients, of whom 238 (46.4%) had a primary liver cancer, and in 148 patients (28.8%), a hepaticojejunostomy was performed; 90-day mortality occurred in 56 patients (10.8%). Mortality was independently predicted by 5 risk factors: age ≥ 65 years, diabetes mellitus type 2, diagnosis of primary liver cancer, American Society of Anesthesiologists ≥ 3, and extended hemihepatectomy. A risk score with 1 point assigned to each risk factor showed good discrimination (area under the curve [AUC], 0.77; 95% CI, 0.71-0.83). The predicted 90-day mortality was 3.5% for low-risk (0 or 1 points; 53.8% of all patients), 11.1% for intermediate-risk (2 points; 25.3%), and 29.7% for high-risk patients (3-5 points; 20.9%). External validation in the nationwide cohort with 1617 patients showed similar concordance (AUC, 0.69; 95% CI, 0.64-0.75). CONCLUSION:The proposed and validated risk score can aid in shared decision making.

Acute kidney injury (AKI) is a common complication following liver transplantation (LT), with multifactorial etiology. It is believed that perioperative hemodynamic instability could lead to AKI. A temporary portocaval shunt (TPCS) could possibly prevent this, but its beneficial effect is still controversial, especially in caval-sparing LT. Therefore, the aim of this study was to evaluate whether the use of a TPCS during hepatectomy reduces the incidence and severity of post-LT AKI in caval-sparing LT, defined according to AKIN criteria. Between January 2005 and August 2023, all orthotopic LTs performed in a single center were retrospectively analyzed and were divided into a TPCS group (n = 134) and a no-TPCS group (n = 260). Serum creatinine was collected right before LT and daily during the first week post-LT. In multivariate analysis, TPCS was not related to AKI, while diabetes mellitus (p = 0.01) and LabMELD (p = 0.02) were. When comparing TPCS and no-TPCS groups, no differences were seen in median increase of serum creatinine post-LT (TPCS; 12 µmol/L (-4-52) versus no-TPCS; 14 µmol/L ± (-3-52) (p = 0.94)), number of post-LT AKI (TPCS; 31% versus no-TPCS; 33% (p = 0.57)), or severity of post-LT AKI (p = 0.90). In conclusion, the application of a TPCS during hepatectomy is not associated with less post-LT AKI or less severe post-LT AKI when using a caval-sparing LT technique.

In this study, 10 years of procurement quality monitoring data were analyzed to identify potential risk factors associated with procurement-related injury and their association with long-term graft survival. All deceased kidney, liver, and pancreas donors from 2012 to 2022 and their corresponding recipients in the Netherlands were retrospectively included. The incidence of procurement-related injuries and potential risk factors were analyzed. Of all abdominal organs procured, 23% exhibited procurement-related injuries, with a discard rate of 4.0%. In kidneys and livers, 23% of the grafts had procurement-related injury, with 2.5% and 4% of organs with procurement-related injury being discarded, respectively. In pancreas procurement, this was 27%, with a discard rate of 24%. Male donor gender and donor BMI >25 were significant risk factors for procurement-related injury in all three abdominal organs, whereas aberrant vascularization was significant only for the kidney and liver. In the multivariable Cox regression analyses, procurement-related injury was not a significant predictor for graft failure (kidney; HR 0.99, 95% CI 0.75-1.33, p = 0.99, liver; HR 0.92, 95% CI 0.66-1.28, p = 0.61, pancreas: HR 1.16; 95% CI 0.16-8.68, p = 0.88). The findings of this study suggest that transplant surgeons exhibited good decision-making skills in determining the acceptability and repairability of procurement-related injuries.

An introductory section covering basic aspects of the mechanisms of ischemia reperfusion and organ dysfunction. The singularities of different preservation solutions will be addressed. The impact of the use of suboptimal liver grafts and clues to made the right trade-off between benefit and risk will be discussed.

Purpose The aim of this study was to investigate the biodistribution of (super-)selective trans-arterial radioembolization (TARE) with holmium-166 microspheres ( 166 Ho-MS), when administered as adjuvant therapy after RFA of HCC 2–5 cm. The objective was to establish a treatment volume absorbed dose that results in an absorbed dose of ≥ 120 Gy on the hyperemic zone around the ablation necrosis (i.e., target volume). Methods In this multicenter, prospective dose-escalation study in BCLC early stage HCC patients with lesions 2–5 cm, RFA was followed by (super-)selective infusion of 166 Ho-MS on day 5–10 after RFA. Dose distribution within the treatment volume was based on SPECT-CT. Cohorts of up to 10 patients were treated with an incremental dose (60 Gy, 90 Gy, 120 Gy) of 166 Ho-MS to the treatment volume. The primary endpoint was to obtain a target volume dose of ≥ 120 Gy in 9/10 patients within a cohort. Results Twelve patients were treated (male 10; median age, 66.5 years (IQR, [64.3–71.7])) with a median tumor diameter of 2.7 cm (IQR, [2.1–4.0]). At a treatment volume absorbed dose of 90 Gy, the primary endpoint was met with a median absorbed target volume dose of 138 Gy (IQR, [127–145]). No local recurrences were found within 1-year follow-up. Conclusion Adjuvant (super-)selective infusion of 166 Ho-MS after RFA for the treatment of HCC can be administered safely at a dose of 90 Gy to the treatment volume while reaching a dose of ≥ 120 Gy to the target volume and may be a favorable adjuvant therapy for HCC lesions 2–5 cm. Trial registration Clinicaltrials.gov NCT03437382 . (registered: 19-02-2018)

BackgroundDisseminated disease (DD) is often found at (re-)exploration in gallbladder cancer (GBC) patients. We aimed to assess the yield of staging laparoscopy (SL) and identify predictors for DD.MethodsThis retrospective study included patients from all Dutch academic centres with primary GBC (pGBC) and incidentally diagnosed GBC (iGBC) planned for (re-)resection. The yield of SL was determined. In iGBC, predictive factors for DD were assessed.ResultsIn total, 290 patients were included. Of 183 included pGBC patients, 143 underwent laparotomy without SL, and 42 (29%) showed DD perioperatively. SL, conducted in 40 patients, identified DD in eight. DD was found in nine of 32 patients who underwent laparotomy after SL.Of 107 included iGBC patients, 100 underwent laparotomy without SL, and 19 showed DD perioperatively. SL, conducted in seven patients, identified DD in one. Cholecystitis (OR = 4.25; 95% CI 1.51-11.91) and primary R1/R2 resection (OR = 3.94; 95% CI 1.39-11.19) were independent predictive factors for DD.ConclusionsIn pGBC patients, SL may identify DD in up to 20% of patients and should be part of standard management. In iGBC patients, SL is indicated after primary resection for cholecystitis and after initial R1/R2 resection due to the association of these factors with DD.

BACKGROUND:Currently, no practical definition of potentially resectable, borderline or unresectable perihilar cholangiocarcinoma (pCCA) is available. Aim of this study was to define criteria to categorize patients for use in a future neoadjuvant or induction therapy study. METHOD:Using the modified DELPHI method, hepatobiliary surgeons from all tertiary referral centers in the Netherlands were invited to participate in this study. During five online meetings, predefined factors determining resectability and additional factors regarding surgical resectability and operability were discussed. RESULTS:The five online meetings resulted in 52 statements. After two surveys, consensus was reached in 63% of the questions. The main consensus included a definition regarding potential resectability. 1) Clearly resectable: no vascular involvement (≤90°) of the future liver remnant (FLR) and expected feasibility of radical biliary resection. 2) Clearly unresectable: non-reconstructable venous and/or arterial involvement of the FLR or no feasible radical biliary resection. 3) Borderline resectable: all patients between clearly resectable and clearly unresectable disease. CONCLUSION:This DELPHI study resulted in a practical and applicable resectability, or more accurate, an explorability classification, which can be used to categorize patients for use in future neoadjuvant therapy studies.

Background & Aims: In the USA, inequal liver transplantation (LT) access exists between patients with and without hepatocellular carcinoma (HCC). Survival benefit considers survival without and with LT and could equalise LT access. We calculated bias-corrected LT survival benefit for patients with(out) HCC who underwent a transplant, based on longitudinal data in a recent United States cohort. Methods: Adult LT candidates with(out) HCC between 2010 and 2019 were included. Waitlist survival over time was contrasted to post-transplant survival, to estimate 5-year survival benefit from the moment of LT. Waitlist survival was modelled with a bias-corrected Cox regression, and post-transplant survival was estimated through Cox proportional hazards regression. Results: Mean HCC survival without LT was always lower than non-HCC waitlist survival. Below model for end-stage liver disease (sodium) (MELD(-Na)) 30, patients with HCC gained more life-years from LT than patients without HCC at the same MELD(-Na) score. Only patients without HCC below MELD(-Na) 9 had negative benefit. Most patients with HCC underwent a transplant below MELD(-Na) 14, and most patients without HCC underwent a transplant above MELD(-Na) 26. Liver function [MELD(-Na), albumin] was the main predictor of 5-year benefit. Therefore, during 5 years, most patients with HCC gained 0.12 to 1.96 years from LT, whereas most patients without HCC gained 2.48 to 3.45 years. Conclusions: On an individual level, performing a transplant in patients with HCC resulted in survival benefit. However, on a population level, benefit was indirectly decreased, as patients without HCC were likely to gain more survival owing to decreased liver function. For patients who underwent a transplant, a constructed online calculator estimates 5-year survival benefit given specific patient characteristics. Survival benefit scores could serve to equalise LT access. Impact and implications: Benefit is a comparison of the survival with and without liver transplantation, and it is important when deciding who should undergo a transplant. Liver function is most important when predicting possible benefit from transplantation. Patients with liver cancer die sooner on the waiting list than similar patients without liver cancer. However, patients with liver cancer more often have better liver function. Most patients without liver cancer derive more benefit from transplantation than patients with liver cancer.

BACKGROUND:The administration of contrast medium is associated with acute kidney injury; however, the effect of exposure of a deceased organ donor to contrast medium on kidney transplant outcomes has been poorly studied. METHODS:A retrospective analysis of all deceased kidney donors between 2011 and 2021 and their corresponding recipients in the Netherlands was conducted. Multivariable analyses were performed to assess the associations between contrast medium exposure and delayed graft function (DGF)/graft survival. Linear mixed models were used to assess the differences in mean estimated glomerular filtration rate values in recipients 1 to 6 y after transplantation. RESULTS:In total, 2177 donors and 3638 corresponding kidney graft recipients were included. Twenty-four percent of the donors (n = 520) were exposed to contrast medium, corresponding to 23% of recipients (n = 832). DGF was observed in 36% (n = 1321) and primary nonfunction in 3% (n = 122) of recipients. DGF rates for donation after brain death (DBD) and donation after circulatory death (DCD) donors showed no significant effect of contrast medium exposure ( P  = 0.15 and P  = 0.60 for DBD and DCD donors, respectively). In multivariable analyses, contrast medium administration was not significantly associated with a higher DGF risk (odds ratio 1.06; 95% confidence interval, 0.86-1.36; P  = 0.63) nor was a significant predictor for death-censored graft failure (hazard ratio 1.01; 95% confidence interval, 0.77-1.33; P  = 0.93). Linear mixed models showed no difference in mean estimated glomerular filtration rate values in recipients 1 to 6 y posttransplantation ( P  = 0.78). CONCLUSIONS:This study indicates that contrast medium administration in DBD and DCD donors has no negative effect on early and long-term kidney graft function.

Laparoscopic donor nephrectomy (LDN) is the current gold standard in kidney donation. Mini-incision open donor nephrectomy (MINI) techniques have been used extensively but have become less popular. The aim of the present study was to compare the results and safety of a non-muscle-splitting MINI technique with the current gold standard of LDN. A single center retrospective cohort study of all living donor nephrectomies between 2011 and 2019 was used for the study. The primary outcome of this study was short term (<30 days) with Clavien–Dindo grade complications. Secondary outcomes included multivariable regression analysis of perioperative data. No differences in complication rates were observed between MINI and LDN and also after correction for known confounders. As expected, the operative time and first warm ischemia were significantly shorter in the MINI group and less blood loss was observed in the LDN group. Complications and conversion rate (LDN to open) among the LDN patients were in line with recent published meta-analyses. This study confirms the perioperative safety of living kidney donation in modern practice. Complication rates of both MINI and LDN procedures are limited and not different between procedures. In specific circumstances, the MINI procedure can still be considered a safe and feasible alternative for living kidney donation.

Organ transplantation is performed worldwide, but policies regarding donor imaging are not uniform. An overview of the policies in different regions is missing. This study aims to investigate the various protocols worldwide on imaging in deceased organ donation. An online survey was created to determine the current policies. Competent authorities were approached to fill out the survey based on their current protocols. In total 32 of the 48 countries approached filled out the questionnaire (response rate 67%). In 16% of the countries no abdominal imaging is required prior to procurement. In 50%, abdominal ultrasound (US) is performed to screen the abdomen and in 19% an enhanced abdominal Computed Tomography (CT). In 15% of the countries both an unenhanced abdominal CT scan and abdominal US are performed. In 38% of the countries a chest radiographic (CXR) is performed to screen the thorax, in 28% only a chest CT, and in 34% both are performed. Policies regarding radiologic screening in deceased organ donors show a great variation between different countries. Consensus on which imaging method should be applied is missing. A uniform approach will contribute to quality and safety, justifying (inter)national exchange of organs.

BACKGROUND & AIMS:Acute-on-chronic liver failure (ACLF) is usually associated with a precipitating event and results in the failure of other organ systems and high short-term mortality. Current prediction models fail to adequately estimate prognosis and need for liver transplantation (LT) in ACLF. This study develops and validates a dynamic prediction model for patients with ACLF that uses both longitudinal and survival data.METHODS:Adult patients on the UNOS waitlist for LT between 11.01.2016-31.12.2019 were included. Repeated model for end-stage liver disease-sodium (MELD-Na) measurements were jointly modelled with Cox survival analysis to develop the ACLF joint model (ACLF-JM). Model validation was carried out using separate testing data with area under curve (AUC) and prediction errors. An online ACLF-JM tool was created for clinical application.RESULTS:In total, 30,533 patients were included. ACLF grade 1 to 3 was present in 16.4%, 10.4% and 6.2% of patients, respectively. The ACLF-JM predicted survival significantly (p <0.001) better than the MELD-Na score, both at baseline and during follow-up. For 28- and 90-day predictions, ACLF-JM AUCs ranged between 0.840-0.871 and 0.833-875, respectively. Compared to MELD-Na, AUCs and prediction errors were improved by 23.1%-62.0% and 5%-37.6% respectively. Also, the ACLF-JM could have prioritized patients with relatively low MELD-Na scores but with a 4-fold higher rate of waiting list mortality.CONCLUSIONS:The ACLF-JM dynamically predicts outcome based on current and past disease severity. Prediction performance is excellent over time, even in patients with ACLF-3. Therefore, the ACLF-JM could be used as a clinical tool in the evaluation of prognosis and treatment in patients with ACLF.LAY SUMMARY:Acute-on-chronic liver failure (ACLF) progresses rapidly and often leads to death. Liver transplantation is used as a treatment and the sickest patients are treated first. In this study, we develop a model that predicts survival in ACLF and we show that the newly developed model performs better than the currently used model for ranking patients on the liver transplant waiting list.

Liver function is measured regularly in liver transplantation (LT) candidates. Currently, these previous disease development data are not used for survival prediction. By constructing and validating joint models (JMs), we aimed to predict the outcome based on all available data, using both disease severity and its rate of change over time. Adult LT candidates listed in Eurotransplant between 2007 and 2018 (n = 16 283) and UNOS between 2016 and 2019 (n = 30 533) were included. Patients with acute liver failure, exception points, or priority status were excluded. Longitudinal MELD(-Na) data were modeled using spline-based mixed effects. Waiting list survival was modeled with Cox proportional hazards models. The JMs combined the longitudinal and survival analysis. JM 90-day mortality prediction performance was compared to MELD(-Na) in the validation cohorts. MELD(-Na) score and its rate of change over time significantly influenced patient survival. The JMs significantly outperformed the MELD(-Na) score at baseline and during follow-up. At baseline, MELD-JM AUC and MELD AUC were 0.94 (0.92-0.95) and 0.87 (0.85-0.89), respectively. MELDNa-JM AUC was 0.91 (0.89-0.93) and MELD-Na AUC was 0.84 (0.81-0.87). The JMs were significantly (p < .001) more accurate than MELD(-Na). After 90 days, we ranked patients for LT based on their MELD-Na and MELDNa-JM survival rates, showing that MELDNa-JM-prioritized patients had three times higher waiting list mortality.

Background and Aims The United Network for Organ Sharing’s Model for End‐Stage Liver Disease (UNOS‐MELD) score is the basis of liver allocation in the Eurotransplant region. It was constructed 20 years ago in a small US cohort and has remained unchanged ever since. The best boundaries and coefficients were never calculated for any region outside the United States. Therefore, this study refits the MELD (reMELD) for the Eurotransplant region. Approach and Results All adult patients listed for a first liver transplantation between January 1, 2007, and December 31, 2018, were included. Data were randomly split in a training set (70%) and a validation set (30%). In the training data, generalized additive models with splines were plotted for each MELD parameter. The lower and upper bound combinations with the maximum log‐likelihood were chosen for the final models. The refit models were tested in the validation data with C‐indices and Brier scores. Through likelihood ratio tests the refit models were compared to UNOS‐MELD. The correlation between scores and survival of prioritized patients was calculated. A total of 6,684 patients were included. Based on training data, refit parameters were capped at creatinine 0.7‐2.5, bilirubin 0.3‐27, international normalized ratio 0.1‐2.6, and sodium 120‐139. ReMELD and reMELD‐Na showed C‐indices of 0.866 and 0.869, respectively. ReMELD‐Na prioritized patients with 1.6 times higher 90‐day mortality probabilities compared to UNOS‐MELD. Conclusions Refitting MELD resulted in new lower and upper bounds for each parameter. The predictive power of reMELD‐Na was significantly higher than UNOS‐MELD. ReMELD prioritized patients with higher 90‐day mortality rates. Thus, reMELD(‐Na) should replace UNOS‐MELD for liver graft allocation in the Eurotransplant region.

BACKGROUND:Based on excellent outcomes from high-volume centres, laparoscopic liver resection is increasingly being adopted into nationwide practice which typically includes low-medium volume centres. It is unknown how the use and outcome of laparoscopic liver resection compare between high-volume centres and low-medium volume centres. This study aimed to compare use and outcome of laparoscopic liver resection in three leading European high-volume centres and nationwide practice in the Netherlands. METHOD:An international, retrospective multicentre cohort study including data from three European high-volume centres (Oslo, Southampton and Milan) and all 20 centres in the Netherlands performing laparoscopic liver resection (low-medium volume practice) from January 2011 to December 2016. A high-volume centre is defined as a centre performing >50 laparoscopic liver resections per year. Patients were retrospectively stratified into low, moderate- and high-risk Southampton difficulty score groups. RESULTS:A total of 2425 patients were included (1540 high-volume; 885 low-medium volume). The median annual proportion of laparoscopic liver resection was 42.9 per cent in high-volume centres and 7.2 per cent in low-medium volume centres. Patients in the high-volume centres had a lower conversion rate (7.4 versus 13.1 per cent; P < 0.001) with less intraoperative incidents (9.3 versus 14.6 per cent; P = 0.002) as compared to low-medium volume centres. Whereas postoperative morbidity and mortality rates were similar in the two groups, a lower reintervention rate (5.1 versus 7.2 per cent; P = 0.034) and a shorter postoperative hospital stay (3 versus 5 days; P < 0.001) were observed in the high-volume centres as compared to the low-medium volume centres. In each Southampton difficulty score group, the conversion rate was lower and hospital stay shorter in high-volume centres. The rate of intraoperative incidents did not differ in the low-risk group, whilst in the moderate-risk and high-risk groups this rate was lower in high-volume centres (absolute difference 6.7 and 14.2 per cent; all P < 0.004). CONCLUSION:High-volume expert centres had a sixfold higher use of laparoscopic liver resection, less conversions, and shorter hospital stay, as compared to a nationwide low-medium volume practice. Stratification into Southampton difficulty score risk groups identified some differences but largely outcomes appeared better for high-volume centres in each risk group.

Background: Liver cirrhosis can cause Portal Hypertension (PH) by increased intrahepatic vascular resistance. Recipients with PH have an increased perioperative bleeding risk in orthotopic Liver Transplantation (LT). Temporary Portocaval Shunts (TPCS) and initial Arterial Reperfusion (IAR) have been introduced as techniques to reduce perioperative blood loss in LT. However, the beneficial effect of both techniques is still controversial and little is known about the use of both techniques in recipients with versus without PH. The aim of this study was to evaluate the effect of a TPCS and IAR in LT on peroperative blood loss in patients with PH (PH group) and without PH (no-PH group). Methods: Peroperative transfusion requirement of packed Red Blood Cells (RBC) was used as a surrogate marker for peroperative blood loss. Between January 2005 and May 2017 all orthotopic, first LTs (n=214) performed in a single center were retrospectively analyzed. Results: Multivariate analysis in the no-PH group showed that using a TPCS significantly decreased peroperative blood loss (p=0.01). Instead, in the PH group, using IAR significantly decreased peroperative blood loss (p<0.001). Conclusion: Using IAR in LT significantly decreases peroperative blood loss in recipients with PH, whereas in recipients without PH a TPCS leads to significantly less peroperative blood loss. Therefore, the use of these techniques, potentially both or depending on presence of PH could be considered in patients receiving LT.