Sequential vs simultaneous revascularization in patients undergoing liver transplantation: A meta-analysis

Abstract

Aim: We undertook this meta-analysis to investigate the relationship between revascularization and outcomes after liver transplantation.

Methods: A literature search was performed using MeSH and key words. The quality of the included studies was assessed using the Jadad Score and the Newcastle-Ottawa Scale. Heterogeneity was evaluated by the χ(2) and I (2) tests. The risk of publication bias was assessed using a funnel plot and Egger's test, and the risk of bias was assessed using a domain-based assessment tool. A sensitivity analysis was conducted by reanalyzing the data using different statistical approaches.

Results: Six studies with a total of 467 patients were included. Ischemic-type biliary lesions were significantly reduced in the simultaneous revascularization group compared with the sequential revascularization group (OR = 4.97, 95%CI: 2.45-10.07; P < 0.00001), and intensive care unit (ICU) days were decreased (MD = 2.00, 95%CI: 0.55-3.45; P = 0.007) in the simultaneous revascularization group. Although warm ischemia time was prolonged in simultaneous revascularization group (MD = -25.84, 95%CI: -29.28-22.40; P < 0.00001), there were no significant differences in other outcomes between sequential and simultaneous revascularization groups. Assessment of the risk of bias showed that the methods of random sequence generation and blinding might have been a source of bias. The sensitivity analysis strengthened the reliability of the results of this meta-analysis.

Conclusion: The results of this study indicate that simultaneous revascularization in liver transplantation may reduce the incidence of ischemic-type biliary lesions and length of stay of patients in the ICU.

Keywords: Biliary complications; Liver transplantation; Meta-analysis; Outcomes; Revascularization.

Figure 1

Flow diagram of the included studies.

Figure 2

Meta-analysis results of incidence of ischemic-type biliary lesions. The occurrence of incidence of ischemic-type biliary lesions was significantly reduced in the SimR group over the SeqR group (OR = 4.97, 95%CI: 2.45-10.07, P < 0.00001). SeqR: Sequential revascularization; SimR: Simultaneous revascularization.

Figure 3

Meta-analysis results of blood cell and plasma transfusions. A: Three studies were conducted to compare units of blood cell (MD = 0.55, 95%CI: -0.84-1.94, P = 0.44); B: Two studies were conducted to compare plasma transfusions (MD = -416.71, 95%CI: -997.01-163.59, P = 0.16).

Figure 4

Meta-analysis results of intensive care unit and total hospital days. A: SimR significantly decreased intensive care unit days (MD = 2.00, 95%CI: 0.55-3.45, P = 0.007); B: No significant difference was shown in total hospital days (MD = 0.46, 95%CI: -1.99-2.90, P = 0.71).

Figure 5

Meta-analysis results of total operation time and warm ischemia time. A: There was no significant difference in total operation time (MD = 22.59, 95%CI: -4.79-49.96, P = 0.11); B: SimR significantly prolonged warm ischemia time (WIT) (MD = -25.84, 95%CI: -29.28-22.40, P < 0.00001). However, the results of χ² and I² tests in WIT showed heterogeneity (P = 0.05, I² = 75%).

Figure 6

Meta-analysis results of graft failure and mortality in one month and one year. A: There were no significant differences in graft failure in one month (OR = 1.19, 95%CI: 0.50-2.81, P = 0.70); B: There were no significant differences in mortality in one month (OR = 1.44, 95%CI: 0.57-3.68, P = 0.44); C: There were no significant differences in graft failure in one year (OR = 1.31, 95%CI: 0.57-3.04, P = 0.53); D: There were no significant differences in mortality in one year (OR = 0.83, 95%CI: 0.39-1.78, P = 0.64).

Figure 7

Funnel plot and Egger’s test of studies on incidence of ischemic-type biliary lesions. A: Funnel plot was not strictly symmetrical; B: Egger’s test did not show publication bias (P = 0.136).

Figure 8

Risk of bias graph: review authors’ judgments regarding each risk of bias item for each included study.

Figure 9

Sensitivity analysis of this meta-analysis. The sensitivity analysis showed the same effect sizes among different models. A: A fixed effects model (P < 0.00001); B: A random effects model (P = 0.002); C: A fixed effects model after excluding the greatest weight study (P < 0.00001).