Audrey E. Brown

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Building on models developed for recipients of deceased donor liver transplant, a modified early allograft dysfunction score of bilirubin>10 or INR>1.6 at postoperative day 7 has been applied to patients undergoing living donor liver transplant. However, this score has never been validated in the living donor liver transplant population or separately analyzed in patients receiving left lobe (LL) grafts. A multicenter cohort of patients (Adult-to-Adult Living Donor Liver Transplantation Cohort Study [A2ALL]) and a single-center cohort University of California, San Francisco (UCSF) were combined. Kaplan-Meier estimates were computed for graft loss (GL), and Cox proportional hazards models were used to evaluate lab values from 1-week post-transplant. Separate multivariable risk scores for GL in recipients of right lobe (RL) and LL were created and bootstrap-validated, and their risk associations compared to modified early allograft dysfunction. In total, 724 and 156 patients with RL and LL grafts, respectively, were included in this analysis. GL occurred in 7.5% of patients with RL and 7.8% patients with LL. Recipients of RL who scored above the RL score cut-point and recipients of LL who scored above the LL score cut-point had a significantly higher risk of GL (RL: HR 6.00, 95% CI: 3.15–11.4, p p p p =0.24). We developed and validated separate risk scores for recipients of RL and LL, which may allow for earlier and more accurate identification of patients at high risk of GL and early intervention to protect the graft.

Background: Multiple intraoperative hemodynamic parameters are associated with an increased risk of early allograft dysfunction (EAD) following living donor liver transplantation (LDLT); however, there is significant center‐to‐center variability in terms of which parameters are used. We sought to determine which intraoperative hemodynamic parameters are most predictive of EAD following LDLT.Methods: This is a systematic review following PRISMA guidelines (PROSPERO ID: CRD42023409711). Receiver operating characteristic (ROC) analyses were used to compare predictive parameters.Results: A total of 4399 articles were identified from 3 large, international databases (PubMed, Embase, and Web of Science). Eighteen articles fit the inclusion criteria. The most commonly evaluated hemodynamic parameter was the postreperfusion portal venous pressure (PVP). A postreperfusion PVP of <15–20 mmHg was consistently associated with lower rates of EAD and, in some cases, improvements in patient survival. Other hemodynamic parameters evaluated included portal venous flow, hepatic arterial flow, portal venous velocities, and the hyperperfusion index.Conclusion: Hemodynamic measurements indicative of portal hyperperfusion, especially elevated PVP, have been consistently associated with the development of EAD. Intraoperative hemodynamics should be monitored on all LDLT recipients, with portal inflow modulation procedures indicated if portal hyperperfusion is present.

Pancreatoblastoma is perceived to be aggressive in adults; however, data are limited due to the rarity of the disease. We benchmarked clinico-pathologic characteristics, outcomes, and survival of adult patients with pancreatoblastoma to a comparable PDAC cohort using the National Cancer Database (NCDB). This study included 301,204 patients: 35 with pancreatoblastoma and 301,169 PDAC patients. Pancreatoblastoma patients were younger than PDAC patients (56 vs. 69 years, p < 0.001). More pancreatoblastoma patients were managed at academic institutions (63.0% vs. 40.7%, p = 0.047). The most frequent primary site was the head and the neck of the pancreas. There were no differences in tumor size (4.2 cm vs. 3.7 cm, p = 0.828), lymph node positivity (14.3% vs. 26.4%, p = 0.103), or metastasis at time of diagnosis (31.4% vs. 46.1%, p = 0.081). The majority of pancreatoblastoma patients underwent resection compared to a minority of PDAC patients (69.7% vs. 15.5%, p < 0.001). Time from diagnosis to surgery was longer for pancreatoblastoma patients (33 vs. 14 days, p = 0.030). Pancreaticoduodenectomy was the most common type of resection in the pancreatoblastoma and PDAC groups (47.8% vs. 67.7%, p = 0.124). Among resected patients, pancreatoblastoma patients were less likely to receive radiation (4.8% vs. 37.0%, p = 0.002), but the use of chemotherapy was similar to PDAC patients (60.9% vs. 70.7%). After matching, median overall survival was longer for pancreatoblastoma than PDAC (59.8 months vs. 15.2 months, p = 0.014).

Background: Transplant surgery has historically been a less desirable fellowship among general surgery graduates. Limited work has been done to understand factors associated with residents’ interest in transplantation. Using a multi‐institutional cohort, we examined how the resident experience on transplant surgery may influence their decision to pursue transplant fellowship.Methods: Individual demographics, program characteristics, and transplant‐specific case logs were collected for graduates from 2010 to 2020 at 20 general surgery residency programs within the US Resident OPerative Experience (ROPE) Consortium. Residents who pursued transplant surgery fellowship were compared to those who went directly into practice or pursued a non‐transplant fellowship.Results: Among 1342 general surgery graduates, 52 (3.9%) pursued abdominal transplant fellowship. These residents completed more transplant (22 vs. 9), liver (14 vs. 9), pancreas (15 vs. 11), and vascular access operations (38 vs. 30) compared to residents who did not pursue transplant fellowship (all p < 0.05). Multivariable logistic regression found that residents underrepresented in medicine were three times more likely (95% CI 1.54–6.58, p < 0.01) and residents at a program co‐located with a transplant fellowship six times more likely (95% CI 1.95–18.18, p < 0.01) to pursue transplant fellowship. Additionally, a resident's increasing total transplant operative volume was associated with an increased likelihood of pursuing a transplant fellowship (OR = 1.12, 95% CI 1.09–1.14, p < 0.01).Conclusion: The findings from this multi‐institutional study demonstrate that increased exposure to transplant operations and interaction within a transplant training program is associated with a resident's pursuit of transplant surgery fellowship. Efforts to increase operative exposure, case participation, and mentorship may optimize the resident experience and promote the transplant surgery pipeline.

The wait times for patients with hepatocellular carcinoma (HCC) listed for liver transplant are longer than ever, which has led to an increased reliance on the use of pre-operative LRTs. The impact that multiple rounds of LRTs have on peri-operative outcomes following transplant is unknown. This was a retrospective single center analysis of 298 consecutive patients with HCC who underwent liver transplant (January 2017 to May 2021). The data was obtained from two institution-specific databases and the TransQIP database. Of the 298 patients, 27 (9.1%) underwent no LRTs, 156 (52.4%) underwent 1-2 LRTs, and 115 (38.6%) underwent ≥3 LRTs prior to LT. The patients with ≥3 LRTs had a significantly higher rate of bile leak compared to patients who received 1-2 LRTs (7.0 vs. 1.3%, p = 0.014). Unadjusted and adjusted regression analyses demonstrated a significant association between the total number of LRTs administered and bile leak, but not rates of overall biliary complications. The total number of LRTs was not significantly associated with any other peri-operative or post-operative outcome measure. These findings support the aggressive use of LRTs to control HCC in patients awaiting liver transplant, with further evaluation needed to confirm the biliary leak findings.

Accurate preoperative staging of gastric cancer is essential, because the median survival for advanced gastric cancer is only 3 months in population studies. Me