Andrew Min-Gi Park

Ectopic positioning of the gallbladder within the hepatic parenchyma is uncommon and can substantially increase surgical complexity. A 25-year-old woman with gastroschisis, prior abdominal operations, short bowel syndrome, and gastroileostomy bypass presented with recurrent acute cholecystitis despite prior drainage and stenting. Laparoscopy was abandoned due to dense adhesions preventing exposure, prompting open exploration. The gallbladder was discovered buried in the liver and was accessed safely through limited parenchymal transection followed by dome-down dissection. After confirmation of a single outflow tract, the inflamed infundibular-cystic duct region was divided with a linear stapler. Ultimately, subtotal cholecystectomy was avoided due to her altered gastrointestinal anatomy, making postoperative endoscopic management difficult in the event of a leak or retained remnant. Nevertheless, she recovered uneventfully and was discharged on postoperative day 2. This case emphasizes the importance of individualized operative strategy when aberrant anatomy coexists with limited rescue options.

Background: Primary graft dysfunction (PGD) represents a leading cause of mortality in patients undergoing donation after brain death (DBD) orthotopic heart transplantation (OHT), requiring timely escalation to mechanical circulatory support. There is a lack of nationwide data regarding PGD after donation after circulatory death (DCD). Here, we evaluated the incidence and short‐term outcomes of PGD following DCD.Methods: Using the UNOS registry between 9/2023 and 9/2024, we identified all adult (≥18 years) recipients of OHT. The incidence and outcomes of moderate‐severe PGD (24‐ and 72‐h post‐transplant) were compared between DCD and DBD. Predictors for mortality after PGD were analyzed using Cox proportional hazard models. 30‐day survival was analyzed using the Kaplan‐Meier method.Results: A total of 5017 patients underwent first‐time OHT, among whom 762 (15.2%) received DCD hearts. DCD had a significantly higher incidence of PGD at 24‐ (7.9% vs. 4.8%; p = 0.001) and 72‐h (5.9% vs. 3.3%; p = 0.001) compared to DBD. 30‐day (p = 0.3068) survival was not different between DCD and DBD patients with PGD. Similarly, for recipients with PGD at 72 h, 30‐day (p = 0.327) survival was comparable. At 72 h, DCD recipients were more likely to be supported on ECMO (p = 0.016). Transplanting DCD organs did not impact PGD‐associated mortality at 24‐ (HR 0.72, p = 0.442) and 72‐h (HR 0.74, p = 0.457). Postoperative ECMO was associated with decreased risk of PGD‐associated mortality in DCD recipients at 24‐ (p < 0.0001) and 72‐h (p < 0.0001).Conclusions: While PGD rates appear higher in DCD, the associated mortality remains comparable to that of DBD. Early support on ECMO may confer survival benefits in DCD recipients with PGD.

Background.: On March 9, 2023, the Composite Allocation Score (CAS) was introduced for all lung transplantation (LT) candidates. We analyzed waitlist and posttransplant outcomes after CAS implementation. Methods.: Using the United Network for Organ Sharing registry (2022–2024), adult patients listed for isolated LT were divided into 2 eras: era 1 (pre-CAS: March 1, 2022–March 8, 2023) and era 2 (post-CAS: March 9, 2023–September 30, 2024). Competing risk regression analyzed waitlist events. Recipient/donor characteristics and mortality risk factors were assessed with Cox models. Survival was evaluated with Kaplan-Meier analysis. Results.: Among 6398 LTs, 2598 (40.6%) occurred in era 2. More Black patients (16.9% versus 15%, P = 0.04) and those with a high school education (35.4% versus 33.4%, P = 0.0003) were transplanted. ABO type O patients were less likely to undergo LT (42.5% versus 46.6%, P = 0.04). Era 2 had longer transport distances (231 versus 202 miles, P < 0.0001), ischemic times (5.1 versus 4.9 h, P < 0.0001), and increased use of flights (79.1% versus 72.8%, P < 0.0001). Donation after circulatory death (9.4% versus 6.2%, P < 0.0001) and normothermic regional perfusion (2.2% versus 1.2%, P = 0.02) usage rose. Waitlist times decreased (29 versus 31 d, P = 0.009), with improved outcomes (sub-hazard ratio, 0.70; P < 0.0001). Era 2 showed superior 6-mo and 1-y survival (P < 0.0001) and reduced rejection treatment (2.6% versus 14.5%, P < 0.0001). Conclusions.: The implementation of CAS was associated with reduced waitlist mortality, improved access for marginalized groups, and enhanced survival. Lungs were procured from greater distances with an increased use of donation after circulatory death with normothermic regional perfusion or ex vivo perfusion. Disparities remain for ABO type O patients, warranting closer follow-up.

Background: The volume of cardiac valve and coronary artery revascularization procedures is rising in the United States. This cross-sectional study explores ethnic disparities in mortality in cardiac surgery attributed to mechanical failures of implantable heart valves and coronary artery grafts. Methods: We used the CDC Wide-Ranging Online Data for Epidemiologic Research Multiple Causes of Death database to identify patients whose single cause of death was categorized by complications of cardiovascular prosthetic devices, implants, and grafts (ICD-10 code T82) between 1999 and 2020. The Joinpoint software (version 5.2.0, National Cancer Institute) was used to construct log-linear regression models to estimate the average annual percent changes in age-adjusted mortality (per 100,000). These patterns were compared and stratified by sex, age (0–44, 44–64, and 65 years or older), and US census regions between White, Black, Hispanic, non-Hispanic, American Indian, Alaskan Native, Asian American, and Pacific Islanders. Results: Age-adjusted mortality due to mechanical failures of cardiac implants and grafts declined across ethnicities from 2.21 (95% CI 2.16–2.27) in 1999 to 0.88 (95% CI 0.85–0.91) in 2020. Black populations (1.31 [95% CI 1.20–1.42]), both men (1.56 [95% CI 1.37–1.74]) and women (1.02 [95% CI 0.90–1.15]) experienced higher mortality in 2020 compared to all other ethnicities. This disparity was pronounced in younger groups (age 0–64), wherein age-adjusted mortality among Black populations (0.18 [95% CI 0.13–0.25]) more than doubled that of White populations (0.08 [95% CI 0.06–0.10]). Conclusions: Over the last two decades, age-adjusted mortality due to mechanical complications of cardiovascular implants has declined significantly. However, Black men and women, particularly younger patients, continue to experience higher death rates compared to other ethnicities.

Background: The volume of cardiac valve and coronary artery revascularization procedures are rising in the United States. This cross-sectional study explores ethnic disparities in mortality cardiac surgery attributed to mechanical failures of implantable heart valves and coronary artery grafts. Methods: We used the CDC Wide-Ranging Online Data for Epidemiologic Research Multiple Causes of Death database to identify patients whose single cause of death was categorized by complications of cardiovascular prosthetic devices, implants, and grafts (ICD-10 code T82) between 1999 to 2020. Patterns in age-adjusted mortality (per 100,000) and respective 95% CIs were compared and stratified by sex, age (0-44, 44-64, 65 years or older), and US census regions between White, Black, Hispanic, non-Hispanic, American Indian, Alaskan Native, Asian American, and Pacific Islanders. Results: Age-adjusted mortality due to mechanical failures of cardiac implants and grafts declined across ethnicities from 2.21 (95% CI 2.16-2.27) in 1999 to 0.88 (95% CI 0.85-0.91) in 2020. Black populations (1.31 [95% CI 1.20-1.42]), both men (1.56 [95% CI 1.37-1.74]) and women (1.02 [95% CI 0.90-1.15]), experienced higher mortality in 2020 compared to all other ethnicities. This disparity was pronounced in younger groups (age 0-64), wherein age-adjusted mortality among Black populations (0.18 [95% CI 0.13-0.25]) more than doubled that of White populations (0.08 [95% CI 0.06-0.10]). Conclusions: Over the last two decades, age-adjusted mortality due to mechanical complications of cardiovascular implants have declined significantly. However, Black men and women, particularly younger patients, continue to experience higher death rates compared to other ethnicities.

Background and Objectives: Hepatic resection offers promising outcomes for patients with hepatocellular carcinoma (HCC) but can be constrained by factors like patient suitability. Continuous advancements in laparoscopic and robotic technologies have made minimally invasive hepatectomies (MIHs) a viable alternative to open hepatectomies with benefits in terms of recovery and complications. Materials and Methods: We completed a retrospective review on 138 HCC patients who underwent OH or MIH between 2010 and 2020 at the Hume-Lee Transplant Center. Univariate and multivariate analyses were completed on demographic, clinical, and tumor-specific data to assess the impact of these variables on overall and disease-free survival at 1, 3, and 5 years. Preoperative metrics like length of hospital stay (LOS) and operation duration were also evaluated. Results: Of the 109 OH and 29 MIH patients, MIH patients demonstrated shorter LOS and operative times. However, overall survival (OS) and disease-free survival (DFS) were similar between groups, with no significant variations in 1-, 3-, and 5-year survival rates. Age > 60 years and a lack of preoperative transcatheter arterial chemoembolization (TACE) were significant predictors of inferior OS and DFS in multivariate analyses. Conclusions: MIH is an efficient substitute for OH with comparable survival, even in older patients. The reduced LOS and operation time enhance its feasibility, and older patients previously denied for curative resection may qualify for MIH. Preoperative TACE also enhances survival outcomes, emphasizing its general role in managing resectable HCCs. Both robotic and laparoscopic hepatectomies offer acceptable short- and long-term clinical outcomes, highlighting MIH as the standard choice for HCC patients.

Background: Creating a model for acute liver failure in animal models is essential for research on liver regeneration and cancer. Current surgical techniques allow for a maximum of 80% partial hepatectomy in rats, with low survival rates due to poor inflow control. The common resection technique involves ligation at the liver lobe neck, causing peri-operative blood loss and postoperative blood loss. Methods: A 90% partial hepatectomy was performed on 5 rats using a bile duct-saving portal ligation technique, involving two hilum dissections for bile duct preservation. The first dissection controlled the blood supply to the median and left lateral lobes, and the second to the right inferior and superior lobes. Before closing, all rats were given 5 mL of 10% dextrose intraperitoneally and had access to ClearH₂O DietGel Recovery and 20% dextrose. Weight and behavior were closely monitored for seven days post-operatively. Results: This method resulted in 100% survival, with a 3.1% increase in liver mass and 12.3% increase in liver-to-body mass ratio. Conclusions: This technique is the first bile duct-saving portal ligation for rodent models of acute liver failure, with long-term survival and complete hepatic regeneration. Our procedure offers a viable 90% hepatectomy model for research with improved survival and regeneration outcomes.

Background Hepatic resection offers promising outcomes for patients with hepatocellular carcinoma (HCC) but can be constrained by factors like patient suitability. Continuous advancements in laparoscopic and robotic technologies have made minimally invasive hepatectomies (MIH) viable alternatives to open hepatectomies with benefits in recovery and complications. Materials and Methods We completed a retrospective review on 138 HCC patients at the Hume-Lee Transplant Center that underwent OH or MIH between 2010 and 2020. Univariate and multivariate analyses were completed on demographic, clinical, and tumor-specific data were collected to assess the impact of these variables on overall and disease-free survival at 1-, 3-, and 5-years. Preoperative metrics like length of hospital stay (LOS) and operation duration were also evaluated. Results Of the 109 OH and 29 MIH patients, MIH patients demonstrated shorter LOS and operative times. However, overall survival (OS) and disease-free survival (DFS) were similar between groups, with no significant variations in 1-, 3-, and 5-year survival rates. Ages > 60 years and lack of preoperative transcatheter arterial chemoembolization (TACE) were significant predictors of inferior OS and DFS in multivariate analyses. Conclusions MIH is an efficient substitute to OH with comparable survival even in older patients. The reduced LOS and operation time enhances its feasibility, and older patients previously denied for curative resection may qualify for MIH. Preoperative TACE also enhances survival outcomes, emphasizing its general role in managing resectable HCCs. Both robotic and laparoscopic hepatectomies offer acceptable short- and long-term clinical outcomes, highlighting MIH as the standard choice for HCC patients.

Andrew Park, Kush Savsani, Anjelica Alfonso, Ester Jo, Bryce Hatfield, Daisuke Imai, Aamir Khan, Amit Sharma, Irfan Saeed, Vinay Kumaran, Adrian Cotterell, David Bruno, Yuzuru Sambommatsu, Seung Lee. Ann Hepatobiliary Pancreat Surg -0001;0:. https://doi.org/10.14701/ahbps.24-033