Background & Aims:Liver transplantation (LT) remains the definitive treatment for patients with end-stage chronic liver disease (CLD). However, those transplanted while in the intensive care unit (ICU) represent a high-risk population. Large-scale data on long-term prognosis in this group are limited. We aimed to assess long-term outcomes in patients with CLD undergoing LT from the ICU and to compare outcomes over time. Methods:This retrospective cohort study used the French national transplant registry (CRISTAL). Adults with CLD who underwent LT from the ICU between 2008 and 2018 were included. Organ failures were defined according to EASL CLIF-OF criteria. Five-year survival and associated risk factors were analyzed and compared across four time periods (2008-2010, 2011-2013, 2014-2016, 2017-2018). Results:Among 13,372 LTs performed in France during the study period, 9,686 were for CLD, of which 1,287 (13.2%) patients were in the ICU at the time of LT. Alcohol-related liver disease (50%) and viral hepatitis (16.1%) were the leading etiologies. Five-year survival was significantly lower in ICU patients compared with non-ICU patients (69.2% vs. 79.1%, p <0.0001). Among patients who survived the first post-transplant year, 5-year survival exceeded 83% and was comparable to that of patients with CLD transplanted outside the ICU. Survival by era showed no significant improvement (p = 0.28). Age (hazard ratio [HR] 1.03, p <0.0001), mechanical ventilation (HR 1.57, p = 0.0001) and French donor risk score (HR 1.05, 95% CI [1.02-1.09], p <0.001) were independent predictors of mortality. Conclusion:Patients transplanted from the ICU have significantly lower long-term survival, primarily due to elevated early post-transplant mortality, with no observed improvement over time. Careful candidate evaluation and donor selection remain critical to improving outcomes in this high-risk population.ClinicalTrials.gov number NCT06636409. Impact and implications:This large national cohort study provides a comprehensive evaluation of long-term outcomes in critically ill patients with cirrhosis undergoing liver transplantation while in the intensive care unit. Despite advances in transplant care over the past decade, we observed a persistent survival gap in this high-risk population, primarily driven by increased mortality within the first year after transplantation. Age, the need for mechanical ventilation, and donor-related factors were independently associated with this excess risk. We also found no significant improvement in outcomes over time. These results underscore the continued need for refined candidate selection and donor allocation strategies, taking into account age, pre-transplant clinical stability, and graft quality to optimize post-transplant survival.

BACKGROUND:Split-derived right liver grafts are often considered marginal. This study aimed to compare the long-term outcomes of adult liver transplantation using either whole liver (WL) or right hemi-liver (RHL). METHODS:This single-center retrospective comparative study included liver transplants that were performed between 1991 and 2010. RESULTS:A total of 775 liver transplants were performed, including 70 RHL cases (9%). Donors were younger in the RHL group (25 ± 11 vs. 39 ± 16 years, p=0.001). Complications were similar between the RHL and WL groups, except for bilioma, more frequent in RHL group (11.4% vs. 2.1%, p= 0.001). The median follow-up was 15,9 (1,2-33,9) years. Graft and recipient survival at 1, 3, 5, 10, and 20 years were similar between the groups (p=0.298). After matching for recipient age, donor sex, and transplant indication, the incidence of bilioma was comparable. Independent factors significantly affecting survival were recipient age (HR = 1.027, p=0.009), donor age (HR = 1.012, p=0.014), and duration of cold ischemia (HR = 1.002, p=0.018). CONCLUSION:The very long-term follow-up of this study reinforces the safety and efficacy of RHL transplantation, demonstrating the role in expanding the donor pool without compromising very long-term outcomes.

3589 Background: Following the TRANSMET trial that demonstrated an overall survival (OS) benefit of liver transplantation (LT) over chemotherapy (CT) alone for selected patients with permanently unresectable colorectal liver metastases (uCRLM), the program of LT has continued in France with the same eligibility criteria, independent validation and graft allocation policy. We assessed the real-world oncological outcomes and prognostic factors for post-LT recurrence-free survival (RFS) in the whole cohort. Methods: This nation-wide analysis pooled both patients transplanted in TransMet (Trial cohort) and those after trial closure (Extension cohort). OS and RFS were evaluated in each cohort. Multivariable Cox models for RFS using sensitivity analyses including forced cohort adjustment and bootstrap resampling were performed. Results: A total of 87 patients underwent LT (37 Trial cohort; 50 Extension cohort). Baseline characteristics at CRLM diagnosis were comparable. At LT, patients in the Extension cohort received significantly fewer CT cycles (≥24 cycles, 16% vs 41%, p=0.01) and showed higher rate of partial response (94% vs 57%, p < 0.001) after first-line CT. At time of LT, tumor burden, RECIST status and tumor markers were similar. Median follow-up was shorter in the Extension cohort (16 vs 57 months). No significant differences in OS and RFS were observed between extension and trial cohorts (30-months OS 89% vs 81%; 30-months RFS 47% vs 39%, respectively). In univariable analysis, risk factors of RFS included ≥2 CT lines, ≥24 CT cycles before LT, CEA at LT > 5 ng/mL, progression on CT and interval from primary tumor surgery >2 years. In multivariable Cox analysis, ≥2 lines or >24 cycles before LT (HR 2.90, 95% CI 1.32–6.36; p<0.01) and CEA at LT >5 ng/mL (HR 2.26, 95% CI 1.18–4.33; p=0.01) remained independently associated with RFS, adjusted on interval from primary tumor surgery. Bootstrap resampling (2,000 iterations) highlighted these results in 82% and 67% of models, respectively. Conclusions: LT for uCRLM gives good and reproducible oncological outcomes across trial and extension cohorts. This exploratory analysis supports that RFS is impaired by a prolonged pre-transplant chemotherapy (≥ 2 lines or ≥ 24 cycles) and improved by a good biological response (normalization of CEA), supporting considering LT in a multidisciplinary setting as soon as definitive unresectability is established.

BACKGROUND & AIMS:Liver transplantation (LT) is indicated for liver complications related to hepatitis B virus (HBV) infection: acute liver failure (ALF), decompensated cirrhosis or hepatocellular carcinoma (HCC). The present study aimed to describe and evaluate patient survival after LT for HBV-related disease in France and identify the factors influencing survival. METHODS:The present retrospective cohort study based on medical record information included all adult patients transplanted with positive HBsAg (+/- coinfection with Hepatitis D virus (HDV)) between January 1, 2005 and December 31, 2023 in all French LT centres. RESULTS:The study population consisted of 1083 patients, the majority of whom were men (81.5%) with a median [IQR] age at LT listing of 52.8 [42.5-59.8] years. Indications for LT were HBV-related HCC (47.2%), HBV-related cirrhosis (28.5%), HDV-related cirrhosis (11.2%), HBV-related ALF (10.5%), HDV-related HCC (1.4%) and other (0.7%). Median [IQR] post-LT follow-up was 6.0 [2.2-11.1] years. Patient survival at 1, 5, 10 and 15 years after LT was 91.6%, 80.1%, 71.8% and 63.6% respectively. Multivariate analysis showed that independent significant prognostic factors were age at LT (HR: 1.030; 95CI: 1.019-1.042; p < 0.0001) and the pre-LT nucleos(t)ides analogue (NUC) regimen: in comparison to tenofovir, the use of entecavir alone (HR: 1.735; 95CI: 1.312-2.295; p < 0.0001) or another NUC or combination therapy (HR: 1.471; 95CI: 1.059-2.043; p = 0.021) were associated with decreased survival. CONCLUSIONS:Survival after LT for HBV-related liver disease is good. NUC type prior to LT seems to be associated with patient survival.

BACKGROUND:A significant proportion of patients presenting a primary sclerosing cholangitis (PSC) will require liver transplantation (LT). The present study aimed to investigate graft loss and patient death in a large cohort of patients. METHODS:We conducted a nationwide multicenter retrospective study including all adult patients transplanted for PSC in France From 1985 to 2019. RESULTS:Were included 571 patients; median follow-up after LT was 89.0 months (IQR, 43.0-151.0). Patient survival at 5, 10 and 20 years after LT was 88.2%, 81.2% and 62.6%. After exclusion of patients who died during the first month after LT, 37 patients (6.6%) died during the first 2 years and the main cause was malignancies (n = 15, 40.5%, including 12 cases of recurrent cholangiocellular carcinoma). After 2 years, 90 patients (17.2%) died; the two main causes were malignancies (n = 36, 40.0%, including 13 cases of colorectal cancer) and sepsis (n = 23, 25.6%, of which 7 were related to recurrent PSC). Graft survival at 5, 10 and 20 years was 89.5%,78.7% and 62.7%. Independent factors associated with late patient death (after 2 years) were an older age at LT, a bilio-digestive anastomosis and the use of preventive UDCA; independent factors associated with late graft loss were recurrent PSC, cellular rejection, a younger age at LT, and the use of tacrolimus (protective). CONCLUSIONS:Our results emphasise that the prognosis after LT for PSC could be improved by better detection of cholangiocellular carcinoma before LT, and colorectal cancer after LT.

Few studies have compared the different types of endoscopic biliary drainage, particularly endoscopic retrograde cholangiopancreatography (ERCP) versus Endoscopic ultrasound guided-Choledochoduodenostomy (EUS-CD), for jaundice caused by malignant biliary obstruction prior to pancreatoduodenectomy. Patients were divided into two groups for biliary drainage: ERCP versus EUS-CD. Groups were compared in terms of post-procedure and postoperative morbidity and mortality rates. Overall survival (OS) and disease-free survival (DFS) rates were compared according to the type of BD in patients with pancreatic ductal adenocarcinoma (PDAC). Between June 2016 and April 2023, 110 patients were included (EUS-CD, n = 32; ERCP, n = 78). There were no differences in terms of demographic characteristics, post-procedure morbidity, length of hospital stay, postoperative morbidity, and mortality after propensity score matching. Technical and clinical success rates were similar. Oncological safety did not differ between the groups. Soft pancreatic gland texture was the only factor influencing the occurrence of clinically relevant postoperative pancreatic fistula (p = 0.002). In the matched PDAC subgroup, extended resections were the only factor independently associated with overall survival (p = 0.015), whereas BD type (p = 0.020), patient sex (p = 0.032), and CA 19–9 levels (p = 0.032) were independently associated with disease-free survival. The ERCP group had numerically higher 1-, 3-, and 5-year OS rates than the EUS-CD group, without reaching statistical significance (p = 0.127). No significant difference in DFS was observed between groups (p = 0.694). Postoperative morbidity and mortality were comparable between groups, with no significant differences observed in long-term survival outcomes.

INTRODUCTION:Primary sclerosing cholangitis (PSC) may recur after liver transplantation (LT). We aimed to evaluate the incidence of recurrent PSC (rPSC), its characteristics, and risk factors, in a large cohort with long-term follow-up. METHODS:We conducted a nationwide multicenter retrospective study in France, including all adult patients transplanted for PSC from March 1985 to March 2019. Clinical, biological, and histological data were collected. Risk factors for rPSC were identified using a multivariate Cox-regression model. RESULTS:Five hundred seventy-one patients were included (389 males, 68.1%) with a median age at LT of 42.0 (interquartile range [IQR] 32.0-52.8). Median follow-up after LT was 7.4 years (IQR 3.6-12.6). Overall, rPSC occurred in 25.9% of patients; actuarial risk of developing rPSC at 5, 15, and 25 years was 15.6%, 37.9%, and 52.6%, respectively. The median time to rPSC was 4.9 years (IQR 2.3-8.9). The factors independently associated with rPSC were the presence of IBD (hazard ratio [HR] 1.97, 95% confidence interval [CI] 1.24-3.14), maintenance treatment with corticosteroids (HR 1.76, 95% CI 1.17-2.66), and younger age at LT (HR 1.02 per 1-year increase, 95% CI 1.01-1.03). Type of biliary anastomosis or preventive treatment with ursodeoxycholic acid had no impact on the incidence of rPSC. DISCUSSION:Our results from a large cohort with long-term follow-up strongly confirm that rPSC after LT is frequent. The only modifiable factor associated with rPSC was maintenance treatment with corticosteroids, which could therefore be discontinued in the absence of a specific extrahepatic indication.

3561 Background: Liver transplantation (LT) has recently proved to improve the survival of selected patients with unresectable colorectal liver metastases (uCRLM) compared to chemotherapy (C) alone. However, recurrence rates remain high, stressing the need for a better patient selection. This exploratory study aimed to identify prognostic factors associated with recurrence and death in patients undergoing LT as part of the TransMet trial. Methods: Data from 36 patients of the LT+C arm (per protocol population) were analyzed including age, gender, TNM and RAS status of the primary tumor, characteristics of metastases at diagnosis and at LT, chemotherapy regimen, tumor response (RECIST), and timeframe from primary resection to LT. Associations with recurrence and death were explored. Variables with > 5 observations per group and p-values ≤ 0.10 in univariable analysis were included in multivariable models. Results: Among the 36 transplanted patients, 27 experienced recurrence and 9 died after 50-month follow-up. Recurrence: At univariable analysis two factors were associated to a higher risk: serum CEA levels > 5 ng/ml at time of LT (11/11 vs 11/18, p 0.01) and oxaliplatin-based first line chemotherapy (14/16 vs 13/20, p 0.04). Two other factors showed a trend toward statistical significance: Female sex (14/15 vs 13/21, p 0.10) and > 20 metastases at diagnosis (11/17 vs 16/19, p 0.09). At multivariable analysis, CEA levels at LT > 5 ng/ml (HR: 2.91; 95% CI: 1.0–8.2; p 0.04) emerged as an independent predictor of recurrence. Female sex (HR: 2.2; 95% CI: 0.8–5.3; p 0.08) and oxaliplatin-based first line chemotherapy (HR: 2.0; 95% CI: 0.8–4.8; p 0.13) were also associated with around 2-fold higher risk of recurrence, although not reaching statistical significance. Death : At univariable analysis,two factorswere significantly associated with a higher risk: female sex (7/15 vs 2/21 for male, p 0.03) and > 24 cycles of chemotherapy before LT (8/19 vs 1/15, p 0.05). Two other factors showed a trend toward higher mortality: no response to 1 st line chemotherapy (6/14 vs 3/22, p 0.06) and stable disease (vs partial response) before LT (8/22 vs 1/14, p 0.08). At multivariable analysis, female sex emerged as independent predictor of death (HR 5.1; 95% CI: 1.0-25.0; p = 0.04). More than 24 cycles of chemotherapy (HR 7.1; 95% CI: 0.9 – 51.0; p 0.07) and stable disease (vs partial response) at LT, showed an approximately 7-fold increase in the risk of mortality, although not reaching statistical significance. Conclusions: Within the limits of a reduced sample size, these results suggest that LT should be envisaged early in the history of potential candidates to LT to reduce the number of cycles of chemotherapy. Both morphological and biological tumor response, initially and at time of LT, are essential. The notable influence of female sex on post-LT outcome needs to be further explored. Clinical trial information: NCT02597348 .

Sacrococcygeal chordoma is a malignant, slow-growing, and locally aggressive bone tumor. A wide surgical margin is recommended to prevent local recurrence and metastasis. This disease tends to cause massive defects when rectal resection and sacrectomy are required. Therefore, soft tissue reconstruction is required and a pedicled vertical rectus abdominis muscle flap (VRAM) is a viable option. Important anatomical landmarks, advantages and limitations are discussed and the procedure is described step by step. This case report presents a two-stage operation with an anterior rectal resection and VRAM flap harvest followed by a complementary posterior approach with sacrectomy and soft tissue reconstruction: approach and results. The wound completely healed in six weeks. Three years after surgery, no local recurrence or distal metastasis was detected. This two-stage strategy presents a viable and safe option for large sacrococcygeal chordomas.

Background. Other than location of the primary colorectal cancer (CRC), a few factors are known to influence the intrahepatic distribution of colorectal cancer liver metastases (CRLM). We aimed to assess whether the anatomy of the portal vein (PV) could influence the intrahepatic distribution of CRLM. Patients and methods. Patients with CRLM diagnosed between January 2018 and December 2022 at two tertiary centers were included and imaging was reviewed by two radiologists independently. Intra-operator concordance was assessed according to the intraclass correlation coefficient (ICC). The influence of the diameter, angulation of the PV branches and their variations on the number and distribution of CRLM were compared using Mann-Whitney, Kruskal-Wallis, Pearson's Chi-square and Spearman's correlation tests. Results. Two hundred patients were included. ICC was high (> 0.90, P < 0.001). Intrahepatic CRLM distribution was right-liver, left-liver unilateral and bilateral in 66 (33%), 24 (12%) and 110 patients (55%), respectively. Median number of CRLM was 3 (1-7). Type 1, 2 and 3 portal vein variations were observed in 156 (78%), 19 (9.5%) and 25 (12%) patients, respectively. CRLM unilateral or bilateral distribution was not influenced by PV anatomical variations (P = 0.13), diameter of the right (P = 0.90) or left (P = 0.50) PV branches, angulation of the right (P = 0.20) or left (P = 0.80) PV branches and was independent from primary tumor localisation (P = 0.60). No correlations were found between CRLM number and diameter (R: 0.093, P = 0.10) or angulation of the PV branches (R: 0.012, P = 0.83). Conclusions. PV anatomy does not seem to influence the distribution and number of CRLM.