William C. Chapman

Objective: To report real-world data on hypothermic oxygenated perfusion (HOPE) and normothermic machine perfusion (NMP) in liver transplantation (LT). Summary Background Data: Real-world comparisons between HOPE and NMP are limited and methodologically challenging due to heterogeneity in donor and recipient risk profiles and regional differences in practice patterns. Methods: This international cohort study analyzed consecutive NMP-preserved LTs performed at 15 predominantly North American centers between 2021 and 2025. Outcomes were compared with the European HOPE-REAL cohort, comprising HOPE-treated LTs from 22 centers between 2012 and 2021. Risk-adjusted analyses were performed, stratified by graft type and risk category. Imbalances in baseline characteristics were addressed using entropy balancing. Results: A total of 954 NMP-treated and 1202 HOPE-treated grafts were analyzed, revealing substantial differences in donor risk. Extended-criteria DBD grafts accounted for 30% versus 64%, and futile DCD grafts for 10% versus 30%, in the NMP and HOPE cohorts, respectively. In the NMP cohort, death-censored graft survival at 1, 2, and 3 years exceeded 96% for DBD grafts and 94% for DCD grafts. Comparable outcomes were observed in the HOPE cohort, with 93% survival in DBD and 87% in DCD grafts at up to 3 years, despite significantly higher donor risk in the HOPE-DCD cohort. After risk adjustment, death-censored graft survival remained similar between both modalities across graft types and risk categories. Conclusions: Real-world data on HOPE-treated and NMP-treated LT demonstrate excellent outcomes. Nevertheless, compared with HOPE, further high-quality evidence and longer preservation time is needed to substantiate the clinical benefits of NMP in high-risk grafts.

This study describes our institutional experience with robotic hepatectomy, analyzes trends, and evaluates intraoperative and postoperative outcomes stratified by IWATE-defined procedural difficulty. Retrospective cohort study of the first 100 consecutive robotic hepatectomies performed by the abdominal transplant division at a high-volume center (2017–2025). Outcomes were compared across IWATE groups and between early (2017–2021) and late (2022–2025) cohorts. Logistic regression was used to examine the association between IWATE score and conversion to open surgery, 30-day complications, and major complications (Clavien–Dindo ≥ IIIa). Median age was 61 years (IQR 47–70), 52% were female, and 77% had malignant disease. 28% of resections were major. IWATE categories were low in 29%, intermediate 46%, advanced 7%, and expert 18%. Median operative time was 217 min (IQR 160–294), estimated blood loss was 150 mL (IQR 50–300), and length of stay was 3 days (IQR 2–4). Conversion to open surgery occurred in 22% with no emergent cases; 30-day complications occurred in 21%, major complications in 10%, readmission in 5% and 90-day mortality in 1%. Over time, expert cases and major hepatectomies increased without statistically significant differences in conversion or complication rates. Across IWATE groups, operative time, Pringle use, blood loss, transfusion, conversion, and length of stay increased with complexity ( p < 0.001). Each 1-point increase in IWATE score independently increased the odds of conversion (adjusted OR 1.45, 95% CI 1.12–1.88) but not overall or major complications. Robotic hepatectomy was feasible across IWATE-defined difficulty levels while maintaining good perioperative outcomes. Increasing IWATE difficulty was associated with greater intraoperative complexity and a significantly higher likelihood of conversion to open surgery, although it was not independently associated with increased postoperative morbidity.

The indications for robotic surgery in transplant and HPB procedures are rapidly expanding. However, there is growing concern about the adequacy of robotic training during fellowship in preparing trainees for the evolving demands of modern transplant surgery. This is a single center, retrospective review of the robotic experience of 9-abdominal transplant fellows (ASTS) over a 7-year period (2017–2024) at a high-volume center. A 10-question survey was administered to elicit fellow perspective on their training. The 9 fellows participated in 692 of the total 860 robotic cases (80%) performed on the transplant service during the study period. Case breakdown was 337 (49%) transplant and 355 (51%) HPB cases. Fellows performed 91% of the operations on the console and 9% as bedside assistant. All fellows believed that robotic fellowship training will improve a fellow’s job prospects, and 87% felt that indications for robotic approaches in transplant surgery will broaden significantly. Incorporating formal robotic training in transplant surgery fellowships enhances the fellowship experience by better preparing fellows for the challenges of modern transplant surgery.

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