BackgroundRobotic donor hepatectomy (RDH) for living donor liver transplant (LDLT) has emerged as a safe approach globally. Most published reports originate from Asia, with volumes significantly greater than anything reported in the West. Our goal was to establish an RDH program for LDLT, without prior laparoscopic experience, and to describe the institutional safeguards implemented to ensure patient safety.MethodsOur pre-requisites for establishing an RDH program were defined as: (I) open living donor hepatectomy experience; (II) robotic liver resection experience; and (III) a dedicated, experienced, and multidisciplinary team. The graduated approach, incorporating guiding principles and ethical practice, establishment of the surgical team, surgical training and expertise, and program safety, oversight and development are all described. Donor and recipient cohort outcomes, and a learning curve analysis are retrospectively reported.ResultsFifty consecutive RDHs were completed (October 2021 to January 2025), representing the largest North American experience to date. One patient was converted to open for bleeding which was controlled. Donation was aborted, and the patient is well after 18 months. Median donor age was 39 [interquartile range (IQR) 32-46] years, 52% were female. Median donor body mass index (BMI) was 26.7 (IQR 24.5-28.7) kg/m2. Median graft weight was 871 (IQR 792-1,005) g. No donor mortalities occurred. Aberrant biliary anatomy was seen in 17 donors (34%), with outcomes equivalent to those of donors with standard anatomy. Two donors had transection surface bile leaks, managed with drainage and endoscopic retrograde cholangiography (ERCP) with complete resolution. Recipient and graft survival at 90 days were both 94%. Arterial complications occurred in 8%, and biliary complications in 24% of recipients. Median operative time with robotic instruments active was 260 (IQR 227-305) min, and cumulative sum curve (CUSUM) plot analysis determined that a learning time of 270 min was reached after 19 cases.ConclusionsOur results demonstrate RDH can be safely performed with a short learning curve, provided pre-requisite safeguards are established. Lower volumes of LDLT in North America should not be a barrier to adopting RDH in appropriate institutions.
BackgroundArtificial intelligence (AI) is increasingly integrated into medical education. However, levels of AI literacy, attitudes, and use among surgical educators remain unclear. In this study, we focused on Chinese surgical educators and aimed to investigate their AI literacy levels, attitudes towards AI (ATAI), actual usage of AI in teaching, as well as the interrelationship among them and their demographic characteristics.MethodsWe surveyed surgical educators from all 31 mainland Chinese provinces. Participants completed AI literacy and attitudes-toward-AI surveys and reported AI use in teaching as a percentage. Survey statistics and AI use percentage were analyzed against background characteristics. Weighted analyses were conducted using post-stratification weights based on national health statistics. Mediation models were used to evaluate interrelationship among literacy, attitude and usage.ResultsWithin the study sample, significant disparities were found in AI literacy, a negative correlation between AI literacy and both ATAI and AI use was discovered. Structural equation modeling indicated that AI literacy had a statistically significant negative association on AI use (standardized beta =-0.447; P=0.004) in total, 53.8% mediated by attitudes-toward-AI.ConclusionsAI literacy among surgical educators does not necessarily promote AI use; instead, it likely fosters more balanced but cautious attitudes toward AI that reduces adoption. Despite the limitations in sampling methods, our findings still provide important insights into the AI literacy levels and attitudes toward AI among surgeons nationwide, and suggest potential benefits from promoting more equitable and accessible AI training programs.
Background: Steatotic liver grafts are increasingly prevalent due to obesity and metabolic syndrome and are associated with inferior post-transplant outcomes, leading to frequent organ discard and worsening donor shortage. Normothermic machine perfusion (NMP) enables ex situ pharmacological "defatting", but translation is hampered by complex multi-agent cocktails and perfusion-circuit compatibility issues. Rapamycin (RAPA), a clinically approved mammalian target of rapamycin (mTOR) inhibitor, can restore lipid homeostasis by reducing de novo lipogenesis, enhancing autophagy, and promoting fatty acid beta-oxidation through multiple distinct metabolic pathways. The study's objective is to develop and assess a dedicated, ready-to-use RAPA formulation compatible with the ex-situ liver perfusion. Methods: A pharmaceutical-grade RAPA formulation optimized for perfusion use was developed and validated for solubility and stability. Defatting efficacy and cytotoxicity were assessed in steatotic primary human hepatocytes (PHHs) and precision-cut liver slices (PCLS). Ex vivo perfusions were performed using a controlled oxygenated rewarming protocol followed by NMP in porcine livers and discarded human livers. We evaluated adsorption and pharmacokinetics, tissue triglycerides (TG) content, mTOR pathway inhibition (p70S6K1 phosphorylation), histology, and mechanism-of-action gene expression [reverse transcription-quantitative polymerase chain reaction (RT-qPCR)]. Results: The selected formulation [200 nM, 85% dimethyl sulfoxide (DMSO)/15% water] remained stable for up to 24 months when stored at -20 degrees C. In vitro, RAPA reduced intracellular TG content by 20% in steatotic PHHs and by 38% in PCLS, without affecting viability. In a blood-containing circuit without an organ, target RAPA concentrations were reached within minutes and remained stable, with no detectable adsorption to circuit components. In discarded steatotic human livers, RAPA decreased tissue TG by 22% vs. no significant change in vehicle controls, without evidence of treatment-related histological injury. On-target activity was confirmed by decreased phosphorylation of p70S6K1 and transcriptional changes consistent with increased autophagy (LC3, SIRT1) and reduced de novo lipogenesis (FAS, SREBP1), alongside activation of lipid oxidation/export markers. Conclusions: A perfusion-compatible, ready-to-use RAPA formulation enables a single-agent defatting approach of potential translational interest, achieving a measurable TG reduction and mTOR pathway inhibition in preclinical models and discarded human livers. As an exploratory proof-of-concept, this strategy warrants further functional and transplantation studies before clinical evaluation.
Background Minimally invasive donor hepatectomy (MIDH) has been increasingly adopted worldwide, driven by demonstrated benefits to living donors including reduced blood loss, shorter hospital stays, less postoperative pain, and improved cosmetic outcomes. However, prior international consensus statements have focused primarily on indications and safety outcomes, offering limited practical guidance on operative technique. To address this gap, the International Laparoscopic Living Donor Liver Transplantation (iLDLT) and International Laparoscopic Liver Society (ILLS) convened an expert panel to establish technique-focused consensus recommendations for MIDH. Methods A 56-member expert panel comprising surgeons experienced in laparoscopic and robotic donor hepatectomy from 12 countries participated in a structured consensus process. Six working groups addressed key technical domains: port placement and patient positioning, hilum dissection, parenchymal hepatic transection, bile duct division, vascular division and graft retrieval, and anesthesia and pain control. Key questions and draft statements were presented and debated at the 7(th) World Congress of the iLDLT meeting in Shanghai, China, in October 2025. Digital audience voting and independent evaluation by ten international experts were used to determine consensus strength. Results Across all six technical domains, 35 key questions were addressed and consensus recommendations formulated. Strong recommendations were established for port location and patient position, use of cystic duct traction to facilitate hilar dissection, indocyanine green (ICG) fluorescence-guided demarcation of the transection plane, combined Cavitron ultrasonic surgical aspirator (CUSA)-plus-energy device strategy for parenchymal transection, and the "cut-and-clip" technique for bile duct division. Intermittent inflow occlusion (Pringle maneuver) was endorsed as a safe and beneficial adjunct to reduce blood loss. Conclusions These technique-focused consensus recommendations from an international expert panel provide practical, evidence-informed guidance to support the safe and standardized global expansion of MIDH in both laparoscopic and robotic donor hepatectomy.
Background Pancreatic cancer (PC) is frequently accompanied by systemic inflammatory, nutritional, and metabolic disturbances that may influence postoperative survival beyond conventional clinicopathological staging. Oncogenic KRAS mutations also contribute to inflammatory and metabolic reprogramming in PC, suggesting a potential overlap between tumor biology and host systemic vulnerability. Integrative prognostic models incorporating clinicopathological, immunological, and metabolic features may therefore improve postoperative risk stratification after PC resection. We aim to develop and internally validate a composite Clinicopathologic-Immuno-Metabolic Index (CIMI) for postoperative overall survival (OS) stratification in patients undergoing curative-intent resection for PC, and to evaluate its prognostic value across KRAS mutation subgroups. Methods This retrospective study included 333 patients with PC who underwent curative-intent resection at Zhongshan Hospital between January 2020 and December 2021. Clinicopathological, laboratory, molecular, and body-composition data were collected, and preoperative computed tomography (CT)-derived skeletal muscle index (SMI) was evaluated as a candidate body-composition variable. CIMI was developed for OS using least absolute shrinkage and selection operator (LASSO) Cox regression with the one-standard-error rule, followed by unpenalized Cox refitting to reduce shrinkage bias. Model performance was assessed using the C-index, bootstrap-based optimism correction, and time-dependent Brier score. CIMI was evaluated in the overall cohort and stratified by KRAS mutation status; disease-free survival (DFS) was analyzed using Cox regression. Results CT-derived SMI showed sex-specific variation and correlated with body mass index (BMI), hemoglobin, prealbumin, and age, supporting its evaluation as a candidate body-composition marker during CIMI development. Using the one-standard-error rule, LASSO selected seven predictors for the CIMI score: microvascular invasion, tumor (T) stage, node (N) stage, metastasis (M) stage, neutrophil-to-lymphocyte ratio, hemoglobin, and free fatty acids. After unpenalized Cox refitting, CIMI effectively stratified patients by OS. Patients in the high-risk group had a significantly increased risk of death compared with those in the low-risk group [hazard ratio (HR) =2.48, 95% confidence interval (CI): 1.64-3.73; P<0.001]. The apparent C-index was 0.76, and the bootstrap optimism-corrected C-index was 0.66. In subgroup analyses, continuous CIMI remained significantly associated with OS in both KRAS wild-type patients (HR =2.80, 95% CI: 1.79-4.37; P<0.001) and KRAS-mutated patients (HR =2.19, 95% CI: 1.76-2.74; P<0.001), with no significant interaction between CIMI and KRAS mutation status (P=0.348). For DFS, higher T stage, higher N stage, M1 stage, KRAS mutation, and microvascular invasion were independently associated with shorter DFS. Conclusions The revised CIMI, constructed using LASSO-based variable selection followed by unpenalized Cox refitting, was associated with postoperative OS in patients with resected PC and remained prognostically informative across KRAS mutation subgroups. By integrating clinicopathological, inflammatory, nutritional, and metabolic variables, CIMI may provide complementary postoperative risk stratification. External validation in independent cohorts is required before clinical application.
