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. Author manuscript; available in PMC: 2015 Oct 1.
Published in final edited form as: Am J Surg. 2014 Jul 18;208(4):605–618. doi: 10.1016/j.amjsurg.2014.06.006

A Meta-Analysis of Complications following Deceased Donor Liver Transplant

Lisa McElroy 1,2, Amna Daud 2, Ashley Davis 2, Brittany Lapin 2, Talia Baker 2, Michael Abecassis 2, Josh Levitsky 2, Jane L Holl 1, Daniela P Ladner 1,2
PMCID: PMC4172501  NIHMSID: NIHMS615143  PMID: 25118164

Abstract

Background

Liver transplantation is a complex surgery associated with high rates of postoperative complications. While national outcomes data are available, national rates of most complications are unknown.

Data Sources

A systematic review of the literature reporting rates of postoperative complications between 2002 and 2012 was performed. A cohort of 29,227 deceased donor liver transplant recipients from 74 studies was used to calculate pooled incidences were for 17 major postoperative complications.

Conclusions

This is the first comprehensive review of postoperative complications after liver transplantation and can serve as a guide for transplant and non-transplant clinicians. Efforts to collect national data on complications, such as through the National Surgical Quality Improvement Program, would improve the ability to provide patients with informed consent, serve as a tool for individual center performance monitoring, and provide a central source against which to measure interventions aimed at improving patient care.

Keywords: Liver Transplantation, Postoperative Complications, Patient Outcomes, Secondary Analysis

Introduction

Liver transplantation is a lifesaving and highly complex surgery that is associated with high rates of postoperative complications.(1) Data on graft- and patient survival for liver transplant recipients are very effectively collected through the United Network for Organ Sharing, and have provided individual transplant centers a benchmark for comparison. In contrast, national data on postoperative complication rates are very incompletely collected by the United Network for Organ Sharing. Hence, data available to transplant centers to accurately inform their patients about the postoperative risks of liver transplantation and perform internal quality control are largely limited to single-center and anecdotal reports.

Beyond providing information to liver transplant recipients, more comprehensive data on postoperative complications after liver transplantation would allow for clinicians and transplant centers to compare their complication rates and appreciate whether investigations and improvements of complication rates are necessary. The mitigation of higher than expected postoperative complication rates can lead to outcome improvement and significant cost-savings, as complications in liver transplant recipients are more costly than in other surgical populations. For example, pneumonia, which adds an estimated cost of $20,000 for a patient in the general Intensive Care Unit (ICU), adds $100,000 additional cost in an liver transplant recipient.(2)

In an effort to summarize the presently available data in the literature we have performed a review of the clinical literature over the past 10 years, to identify rates of the most frequently reported biliary, vascular, hemorrhagic and thrombotic, renal, pulmonary, infectious, gastrointestinal, and cardiac complications after liver transplantation.

Materials and Methods

Data Sources

A review of the literature was performed to identify studies that reported the incidence of postoperative complications in deceased donor liver transplant recipients within the first year of surgery. Studies were identified through a search of MEDLINE on October 10, 2012, using the Medical Subject Headings “liver transplantation”, “postoperative complications”, “myocardial infarction”, “pericardial effusion”, “anastomotic leak”, “renal failure”, “respiratory failure”, “pneumothorax”, “pulmonary edema”, “deep venous thrombosis”, “pulmonary embolus”, “pleural effusion”, “postoperative hemorrhage”, “cardiac arrest”, “arrhythmia” and “intestinal obstruction”, which were chosen to reflect the most common post-surgical complications in transplant recipients. A manual search of publication bibliographies was also performed.

Study Selection

IRB approval was received prior to collection of any data. Articles were selected for inclusion if they reported an incidence of postoperative complications in deceased donor liver transplant recipients based on human adult studies over the past decade. Articles were excluded if they were not available in English, were published prior to January 1, 2002, or originated from a location other than the United States, Australia, Canada and Europe. Articles focusing on complications related to children, living donor liver transplant, multivisceral, and retransplantation were excluded. Analysis of complications related to immunosuppression, post reperfusion syndrome, and malignancy were excluded. Care was taken to exclude initial reports if follow-up reports were available. Decision for inclusion was made by two physician reviewers (LMM, AD). Discordant decisions between reviewers were advanced to full text review. Further disagreement was resolved by reaching consensus through discussion among the three reviewers.

Data Extraction and Quality Assessment

Data from the selected manuscripts were independently extracted from each study by 3 reviewers (LMM, AD, AED). Discordant data were solved by a consensus among the investigators with guidance from a fourth reviewer (DPL). Incidences of the following complications were extracted: biliary (leak, stricture), vascular (hepatic artery thrombosis, hepatic artery stenosis, portal vein thrombosis, portal vein stenosis), hemorrhagic and thrombotic (hemorrhage, deep vein thrombosis, pulmonary embolus), renal (acute renal failure, temporary dialysis, permanent dialysis), pulmonary (respiratory failure, pulmonary edema, pleural effusion, pneumothorax, hospital acquired pneumonia), infectious (intra-abdominal abscess, peritonitis, sepsis, surgical site infections, bacteremia, urinary tract infections, cytomegalovirus, bacteria, viral, fungal, protozoal), gastrointestinal (bowel obstruction, incisional hernia, gastrointestinal bleed), and cardiac complications (myocardial infarction, pericardial effusion, cardiac arrest, arrhythmia).

Data Synthesis and Analysis

For each complication subgroup (biliary, vascular, hemorrhagic/thrombotic, renal, pulmonary, infectious, gastrointestinal and cardiac), single group proportions were summarized using weighted averages of means and standard deviations for each study reporting the complication of interest. Incidence effect estimates were summarized by using the DerSimonian and Laird random-effects model.(3) Incidence rates were calculated as percentages. Heterogeneity was assessed using the Cochran Q chi-square test and the I2 statistic, and was considered significant if p<0.10 or if I2 was 50% or greater. To explore the potential sources of heterogeneity, we performed additional subset analyses of studies from the United States.

Funnel plots and Egger’s regression test were used to assess the potential risk of publication bias. Statistical analyses were performed using SAS 9.3 statistical software (SAS Institute, Cary, NC) and StatsDirect Ltd. (StatsDirect statistical software. http://www.statsdirect.com. England: StatsDirect Ltd. 2008).

Results

Search results

A schematic of the search algorithm is shown in Figure 1. Our original search criteria returned 8170 studies, 6253 of which were eliminated based on application of our primary exclusion criteria (language, date, animal studies, pediatric studies, and geography) and title review. Abstract review was performed for 1917 studies, 1783 of which were removed. After supplemental search results were added, 134 studies were selected for full text review. Overall, our meta-analysis includes 29,227 deceased donor liver transplant recipients from 74 studies performed between 2002 and 2012. Table 1 lists the characteristics of studies included in our final analysis. Of the studies retained, 26 reported on complications in the United States, 44 in Europe, 2 in Australia, and 4 in Canada; six included information on donation after cardiac death. Six had a prospective design.

Figure 1. Literature search and exclusion schematic.

Figure 1

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Table 1. Included Studies.

Study Reference Subgroup Nation Study Type Outcomes N
1 Abt, 2003 DBD
DCD		 US Retrospective Biliary leak, stricture 221
15
2 Aduen, 2003 US Retrospective Pulmonary Edema 91
3 Aduen, 2005 US Retrospective Pneumonia 401
4 Alsharabi, 2006 Poland Retrospective Biliary leak, stricture 100
5 Alsharabi, 2007 Poland Retrospective Biliary leak, stricture 200
6 Amador, 2005 Spain Retrospective Biliary leak, stricture; bacterial,
viral, fungal, protozoal
infections		 300
7 Baccarani, 2010 Italy Retrospective Biliary leak, stricture 117
8 Benson, 2011 US Retrospective SSI, PNA, UTI, Bacteremia 514
9 Biagioni, 2011 Italy Retrospective Acute Renal Failure 84
10 Bozbas, 2008 Turkey Retrospective Pleural Effusion 130
11 Cabezuelo, 2002 Spain Retrospective Acute Renal Failure 162
12 Cabezuelo, 2006 Spain Retrospective Acute Renal Failure 184
13 Cherian, 2010 UK Retrospective Pulmonary Embolus 214
9
14 Dorobantu, 2010 Italy Retrospective Biliary leak, stricture 487
15 Faenza, 2007 Italy Retrospective Acute Renal Failure 512
16 Foley, 2005 DBD
DCD		 US Retrospective Biliary stricture, HAT, HAS,
PVT, PVS		 553
36
17 Fouad, 2009 >40yo Canada Retrospective Pulmonary edema, MI,
arrhythmia		 197
18 Freise, 2008 US Retrospective Biliary leak, stricture, HAT,
PVT, hemorrhage, DVT, PE,
pulmonary edema, pleural
effusion, pneumothorax,
pneumonia, abscess,
bacteremia, UTI, bacterial, viral,
fungal infections, bowel
obstruction, incisional hernia,
GI bleed, MI, cardiac arrest		 216
19 Fujita, 2007 DBD
DCD		 US Retrospective Biliary leak, stricture, HAT 120
9
24
20 Gainza, 2002 Spain Retrospective Acute Renal Failure 251
21 GarciaPrado,
2008		 Spain Prospective SSI 167
22 Grodzicki, 2011 Poland Retrospective HAT 862
23 Guitard, 2006 France Retrospective Acute Renal Failure 94
24 Hellinger, 2009 US Prospective SSI 370
25 Hellinger, 2011 US Retrospective SSI 103
6
26 Hernandez, 2010 DCD Canada Retrospective HAT, HAS, Biliary stricture 10
27 Herrero, 2007 Spain Retrospective Gastrointestinal bleed 417
28 Ishigami, 2004 US Prospective HAT, HAS 84
29 Junge, 2006 German
y		 Retrospective Acute Renal Failure 135
2
30 Kappa, 2010 US Retrospective Hemorrhage 410
31 Kahn, 2007 Austria Retrospective Incisional Hernia 90
32 Karvellas, 2011 Canada Retrospective Bacteremia 218
33 Krol, 2011 Poland Retrospective Biliary leak, stricture, HAT 84
34 Kundakci, 2010 Turkey Retrospective Acute Renal Failure 112
35 Leithead, 2012 DBD
DCD		 UK Retrospective Acute Renal Failure 88
88
35 Levesque, 2012 France Retrospective Respiratory failure, pulmonary
edema, pleural effusion,
pulmonary embolus,
pneumothorax, pneumonia		 212
36 Linares, 2009 Spain Retrospective Bacterial Infections 340
37 Maluf, 2005 US Retrospective Biliary leak, stricture 202
38 Mark, 2005 Austria Retrospective Sepsis, PNA, viral infections 360
39 Mathur, 2011 US Retrospective Biliary leak, stricture 409
40 Nadim, 2012 US Retrospective Acute Renal Failure 351
41 Nyckowski, 2002 Poland Retrospective Biliary stricture, HAT, PVS 71
42 Oldakowska,
2003		 Poland Retrospective CMV 123
43 Pacholczyk, 2006 Poland Retrospective Biliary leak, stricture 101
44 Pacholczyk, 2011 Poland Retrospective Fungal Infections 175
45 Pakosz-
Golanowska,
2010		 Poland Retrospective HAT, HAS 210
46 Paramesh, 2004 US Retrospective Acute Renal Failure 160
2
47 Patkowski, 2003 Poland Retrospective Biliary leak, stricture 193
48 Pawarode, 2003 US Retrospective Acute Renal Failure 154
49 Pawlak, 2003 Poland Retrospective Biliary leak, Hemorrhage, HAT 193
50 Pellegrino, 2008 Italy Retrospective Pneumonia 71
51 Piazzese, 2004 Italy Retrospective Incisional Hernia 623
52 Pine, 2009 DBD
DCD		 UK Retrospective Biliary leak, stricture, HAT,
HAS, Hemorrhage, Abscess		 39
39
53 Pirat, 2004 Turkey Retrospective Respiratory failure, pulmonary
edema, pleural effusion,
pneumothorax, pneumonia		 44
54 Piselli, 2007 Italy Prospective Bacteremia, viral and fungal
infections		 103
55 Pungpapong,
2006		 US Retrospective Peritonitis 837
56 Rerknimitr, 2002 US Retrospective Biliary leak, stricture 367
57 Safadi, 2009 US Retrospective MI 403
58 Sakai, 2012 US Retrospective Pulmonary Embolus 495
59 Schaeffer, 2009 Obese Canada Retrospective SSI, Incisional hernia 167
60 Sharma, 2010 US Retrospective PVT 117
1
61 Shi, 2003 Australi
a		 Retrospective Incisional Hernia 410
62 Stange, 2003 German
y		 Retrospective HAT 119
2
63 Suarez, 2010 Spain Retrospective PVT 617
64 Sundaram, 2011 US Retrospective Biliary leak, stricture, HAT 179
8
65 Tachopoulou,
2003		 US Retrospective Abscess 459
66 Tarantino, 2008 Italy Prospective Biliary leak, stricture 193
67 Tenza, 2009 Spain Retrospective Pleural Effusion, Acute Renal
Failure		 74
68 Tinti, 2011 Italy Retrospective Acute Renal Failure 44
69 Torre, 2002 Spain Retrospective Bacteremia 405
70 Urbani, 2003 Italy Retrospective Biliary leak, stricture,
hemorrhage		 398
71 Varo, 2002 Spain Retrospective CMV 186
72 Verran, 2003 Australi
a		 Retrospective HAT 415
73 Weiss, 2010 France Prospective Pneumonia 148
74 Welling, 2008 US Retrospective Biliary leak, stricture 213
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CMV: Cytomegalovirus; DBD: Donation after brain death; DCD: Donation after cardiac death; DVT: Deep Vein Thrombosis; GI: Gastrointestinal; HAS: Hepatic Artery Stenosis; HAT: Hepatic Artery Thrombosis; MI: Myocardial Infarction; PE: Pulmonary Embolus; PNA: Pneumonia; PVT: Portal Vein Thrombosis; PVS: Portal Vein Stenosis; SSI: Surgical Site Infection; UK: United Kingdom; US: United States

Pooled proportions of Complications

Table 2 lists the pooled proportions, heterogeneity, and publication bias for complications reported by 4 or more studies. Overall, the incidences of 14 complications were each reported by 5 or more studies. These complications were selected for full quantitative analysis with forest plots shown in Figure 2.

Table 2. Pooled complication incidences, heterogeneity, and bias.
Complication N Pooled
proportion		 95% CI P-Value I2 Egger’s Bias
Biliary
Biliary Leak 6882 0.079 0.055 to 0.107 <0.001 93.0 2.84, p=0.067
Biliary Stricture 7387 0.125 0.099 to 0.154 <0.001 91.2 2.69, p=0.020
Vascular
Hepatic Artery Thrombosis 6758 0.045 0.031 to 0.062 <0.001 85.0 0.56, p=0.584
Hepatic Artery Stenosis 971 0.045 0.015 to 0.089 <0.001 80.1 1.27, p=0.331
Hemorrhagic/Throm botic
Portal Vein Thrombosis 2593 0.042 0.021 to 0.070 <0.001 91.3 3.43, p=0.242
Hemorrhage 1295 0.083 0.046 to 0.131 <0.001 84.9 2.24, p=0.327
Pulmonary Embolus 2860 0.012 0.001 to 0.034 <0.001 91.4 2.03, p=0.364
Renal
Acute Renal Failure 4998 0.299 0.220 to 0.385 <0.001 97.2 6.24, p=0.006
Pulmonary
Pulmonary Edema 457 0.202 0.064 to 0.391 <0.001 97.0 8.84, p=0.077
Pleural Effusion 334 0.379 0.092 to 0.724 <0.001 98.8 −16.02, p=0.344
Pneumonia 1966 0.155 0.054 to 0.195 <0.001 95.7 5.84, p<0.001
Infectious
Intra-Abdominal Abscess 1281 0.044 0.019 to 0.078 <0.001 86.4 1.86, p=0.297
Surgical Site Infection 537 0.118 0.054 to 0.202 <0.001 96.9 9.33, p=0.117
Bacteremia 1796 0.142 0.072 to 0.231 <0.001 95.8 8.23, p=0.020
Viral 979 0.128 0.028 to 0.284 <0.001 97.3 8.42, p=0.043
Fungal 794 0.147 0.119 to 0.176 0.278 22.2 1.29, p=0.734
Gastrointestinal
Incisional Hernia 1506 0.084 0.049 to 0.127 <0.001 85.0 3.74, p=0.046
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Figure 2. Forest Plots of Quantitatively Analyzed Studies.

Figure 2

Figure 2

Figure 2

Figure 2

Figure 2

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Biliary Complications-leak and stricture

23 studies reported rates of biliary complications.(1, 2, 4-26) 19 studies reported rates of bile leak, and 21 studies reported rates of bile stricture. The estimated mean incidence of biliary leak and stricture for all studies combined was 0.079 (95% CI = 0.055 to 0.107) and 0.125 (95% CI = 0.099 to 0.154) respectively.

Vascular Complications-hepatic artery thrombosis, hepatic artery stenosis, portal vein thrombosis, and portal vein stenosis

15 studies reported rates of vascular complications.(1, 6, 7, 10, 14, 15, 18, 19, 24, 27-34) Hepatic artery thrombosis was reported by 13 studies, with a pooled incidence of 0.045 (95% CI=0.031 to 0.062). Rates of hepatic artery stenosis were reported by 5 studies with a combined incidence of 0.045 (95% CI = 0.015 to 0.089). Rates of portal vein thrombosis were reported by 5 studies, with a combined incidence of 0.042 (95% CI = 0.021 to 0.070). Only 2 studies reported rates of portal vein stenosis, which were not included in our quantitative analysis.

Hemorrhagic and Thrombotic Complications-postoperative hemorrhage, deep venous thrombosis and pulmonary embolus

8 studies reported rates of hemorrhagic and thrombotic complications.(1, 10, 19, 21, 24, 35-38) Of these, 5 studies reported rates of postoperative hemorrhage, with an estimated mean incidence of 0.083 (95% CI = 0.046 to 0.131). Four studies reported rates of pulmonary embolus, with a combined incidence of 0.012 (95% CI = 0.001 to 0.034). A single study reported rates of deep vein thrombosis, which was not included in our quantitative analysis.

Renal complications-acute renal failure, with temporary and with permanent need for hemodialysis

14 studies reported rates of renal complications.(39-53) Thirteen studies reported rates of acute renal failure, with a pooled proportion = 0.299 (95% CI = 0.220 to 0.385). 3 studies reported rates of acute renal failure with a temporary need for dialysis (pooled proportion = 0.195 (95% CI = 0.063, 0.377)). Only three studies reported rates of permanent need for hemodialysis, which were not included in quantitative analysis.

Pulmonary complications-respiratory failure, pulmonary edema, pleural effusion, pneumothorax and pneumonia

12 studies reported rates of pulmonary complications.(1, 35, 38, 41, 50, 54-62) Eight studies reported rates of pneumonia, with a combined incidence of 0.115 (95% CI = 0.054 to 0.195). Five studies each reported rates of pulmonary edema (Pooled proportion = 0.202 (95% CI = 0.064, 0.391)) and pleural effusion (combined incidence 0.379 (95% CI = 0.092 to 0.724)). Not included in our quantitative analysis were 3 studies that reported rates of pneumothorax and 2 studies that reported rates of respiratory failure.

Infectious complications-intra-abdominal abscess, peritonitis, sepsis, surgical site infection (SSI), bacteremia, urinary tract infection, cytomegalovirus, bacterial, viral, fungal, protozoan

20 studies reported rates of infectious complications.(1, 11, 19, 21, 35, 58, 63-76) Five studies reported rates of intra-abdominal abscess, with a combined incidence 0.044 (95% CI = 0.019 to 0.078). Six studies reported rates of surgical site infection (Pooled proportion of 0.118 (95% CI = 0.054 to 0.202)). Bacteremia rates were reported by 6 studies, with a combined incidence of 0.142 (95% CI = 0.072 to 0.231). Four studies reported rates of viral infections (pooled proportion of 0.128 (95% CI = 0.028 to 0.284)) and fungal infections (pooled proportion of 0.147 (95% CI = 0.119 to 0.176)) without specific organism or system involvement. Peritonitis, sepsis, urinary tract infection, cytomegalovirus, bacterial and protozoan infections were each reported by less than 3 studies.

Gastrointestinal complications: bowel obstruction, incisional hernia, gastrointestinal bleed

Gastrointestinal complications were reported in 6 studies.(1, 71, 77-82) Incisional hernia was reported in 5 studies, with a pooled proportion of 0.084 (95% CI = 0.049 to 0.127). Gastrointestinal bleed and bowel obstruction were reported in an insufficient number of studies for quantitative analysis.

Cardiac complications: Myocardial Infarction, cardiac arrest, pericardial effusion, and arrhythmia

Cardiac complications were reported in 4 studies.(1, 57, 61, 83) Rates of myocardial infarction, cardiac arrest, pericardial effusion and arrhythmia were reported in an insufficient number of studies for quantitative analysis.

Discussion

Liver transplantation is a lifesaving, complex surgery associated with a high rate of complications. Postoperative morbidity is due to a combination of factors related to the patient polymorbidity, graft quality, surgical procedure and postoperative management. Our analysis is the first to report on the pooled incidence rate of the 17 most frequent postoperative complications following deceased donor liver transplant. Our pooled complication rates are lower than those reported previously in the literature, likely demonstrating advancements in both surgical technique and patient care. Pooled complication rates after liver transplantation are very important, as they provide data beyond single center information and transplant clinician perception. They also provide a resource for setting the expectations of providers, patients and families as part of preoperative informed consent process.

Our review allows centers to distinguish between those complications which might be related to surgical technique and which may be reducible through improvements in patient care. Among the discussed complications, biliary leak and stricture, hepatic artery thrombosis, hepatic artery stenosis, portal vein thrombosis, pleural effusion, intra-abdominal abscess and incisional hernias are commonly believed to be associated with the surgical procedure or surgical technique. Some may be preventable, while others are likely not. In contrast, some of the complications might be mitigated by improvement of the overall care to the liver transplant recipients. For example the 1.2% complication rate of pulmonary embolus, would indicate a significantly higher incidence of deep vein thrombosis, which is known to be reducible with patient care efforts such as diligent placement of sequential compression devices and initiation of heparin once the liver function (e.g., INR) has normalized.(84) Similarly, it is likely that the postoperative pneumonia rate of 15% can be reduced by systematic and intensive pulmonary rehabilitation, such as chest physical therapy, incentive spirometry, early ambulation, short intubation times and other focused interventions, described in general surgery patients.(85) Interestingly the magnitude of the different pooled complication cohorts, seems also reflect the difference in perceived preventability by the transplant community. While biliary complications and infections have large pooled cohorts, pulmonary complications are noticeably smaller. This is most likely due to the fact that biliary complications are deemed preventable, while pleural effusion, for example, is deemed a non-preventable complication directly related to the loss of peritoneal coverage of the diaphragm due to the hepatectomy.

The transplant community has been at the forefront of transparency and quality improvement, and research efforts continue attempts to minimize postoperative morbidity in these incredibly challenging and complex patients. While patient and graft survival are collected rigorously by the United Network for Organ Sharing, there is currently no systematic collection of data on postoperative complications for transplant patients. A national registry of major complications would improve the ability to provide patients with informed consent, serve as a tool for individual center performance monitoring, and provide a central source against which to measure interventions aimed at improving patient care. Successful examples of such registries include the National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry and the National Heart, Lung, and Blood Institute Dynamic Registry.(86) The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) collects and reports postoperative complication rates for many surgical specialties, but currently not for transplant. As complication rates in transplant recipients cannot easily be compared to other patient populations due to the polymorbid nature of end stage organ disease, adding transplant patients to this national data collection effort would allow for individual center and physician feedback, and is likely to provide information that can lead to outcome improvement. Allowing for comparison of centers to the national mean, if appropriately adjusted, might provide focused incentive to improve outcomes where possible in a field where clinicians are extremely motivated to obtain optimal outcomes for their sick patients. Only reliable, consistently collected data will allow for effectively targeted efforts towards preventing complications. This will require uniformly trained personnel and voluntary participation by centers. The American Society of Transplant Surgeons is presently considering in participating in National Surgical Quality Improvement Program for this reason.

A limitation of this study is the heterogeneity between the studies performed. This may be in part due to variation in sample size. The majority of studies included in our review examined less than 1000 patients, and 6 studies examined between 1000 and 2000 patients. Subgroup analysis of studies performed in the United States was conducted to assess for the relationship of different national systems of quality regulation. We found little difference in the results to account for this variability. We also performed subgroup analysis of DCD donors, but again, found no significant difference in rates. In the end, rather than search for an absolute value of these complications, perhaps we should accept that the range is wide and influenced by not only systems level factors but also hospital level factors. This too is a reason to prospectively collect center specific data on postoperative complications after liver transplantation.

In summary, this is the first systematic review of the incidence of the major postoperative complications after liver transplantation, providing an important reference for health care providers and patients. Prospective national collection of complications in form of a registry may offer opportunities to improve outcomes for these very sick patients undergoing a highly complex, but lifesaving operation.

Footnotes

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