Background: Operative time often has been cited as an important factor for postoperative outcomes. Despite this belief, most efforts to improve liver transplant outcomes have largely focused on only patient and donor factors, and little attention has been paid on operative time. The primary objective of this project was to determine the impact of operative time on graft survival after liver transplant. Methods: A retrospective review of 2,877 consecutive liver transplants performed at a single institution was studied. Data regarding recipient, donor, and operative characteristics, including detailed granular operative times were collected prospectively and retrospectively reviewed. Using an instrument variable approach, Cox multivariate modeling was performed to assess the impact of operative time without the confounding of known and unknown variables. Results: Of the 2,396 patients who met the criteria for review, the most important factors determining liver transplant graft survival included recipient history of Hepatitis C (hazard ratio 1.45, P = .02), donor age (hazard ratio 1.23, P = .03), use of liver graft from donation after cardiac death donor (hazard ratio 1.50, P < .01), and operative time (hazard ratio 1.26, P = .01). In detailed analysis of stages of the liver transplant operation, the time interval from incision to anhepatic phase was associated with graft survival (hazard ratio 1.33; P = .02). Conclusion: Using a novel instrument variable approach, we demonstrate that operative time (in particular, the time interval from incision to anhepatic time) has a significant impact on graft survival. It also seems that some of this efficiency is under the influence of the transplant surgeon.
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