Introduction Liver transplantation (LT) significantly improves survival and quality of life for patients with end-stage liver disease. Whilst it is believed that need for LT vastly exceeds organ supply, quantifying the demand accurately is challenging. The performance metrics of the transplant system, such as waitlist mortality, may be misleading as they capture only patients who are referred, evaluated and listed for LT. Although means of increasing organ availability are available, they have financial costs and may be technically and ethically challenging (such as live donation and normothermic regional perfusion). The imperative to embrace these techniques can be obscured if the waitlist is assumed to be representative of the actual demand for transplantation.Methods An international comparative analysis of transplantation, donation and waitlist outcomes versus measures of demand for LT was performed using publicly available data.Results The comparative analysis revealed no correlation between disease prevalence and waitlist metrics across jurisdictions internationally, suggesting that waitlisting practices are largely independent of actual LT demand and are constrained by other factors.Conclusion Adult LT systems globally are supply driven and uncorrelated to demand, implying that all jurisdictions are unable to meet the demand of their community and are limited by the supply of viable organs. The study underscores the inadequacy of waitlist data in representing true demand and highlights the need for improved data to inform LT policy and practice to improve access to this life-enhancing and life-saving treatment.

BACKGROUND:Liver transplantation (LT) is a technically complex procedure frequently performed out-of-hours. While out-of-hours surgery is associated with higher post-operative morbidity and mortality, contemporary LT-specific data are limited. This paper aimed to characterise the impact of operative timing on major post-operative complications following LT. METHODS:All LT from 2019-2024, at Royal Prince Alfred Hospital, Australia, were included. Out-of-hours LT was defined as revascularisation from 7:00pm-7:00am. The primary endpoint was the effect of out-of-hours LT on major postoperative complications. Secondary endpoints included biliary complications, early allograft dysfunction, patient and graft survival. RESULTS:Of 479 consecutive LTs, 160 (33.4%) occurred out-of-hours. Major postoperative complications were more frequent following out-of-hours LT (p = 0.013), with increased rates of delayed abdominal closure (p = 0.003) and renal replacement therapy (p = 0.044). Multivariate analysis demonstrated out-of-hours LT to be an independent risk-factor for major complications (p = 0.041). Anastomotic strictures more commonly occurred after out-of-hours LT (p = 0.009). Long-term graft and patient survival were not significantly different between groups. CONCLUSION:Out-of-hours LT is a significant risk factor for major post-operative complications but not reduced long-term patient or graft survival. Strategies to reduce out-of-hours LT, including expanded machine perfusion utilisation, may improve outcomes.

Background Resection margin status and lymph node involvement are well-established predictors of recurrence following resection of perihilar cholangiocarcinoma (pCCA). However, even patients with favorable pathology including negative surgical margins (R0) and node-negative disease (N0) may experience recurrence. We sought to develop a clinically relevant tool to risk stratify patients relative to tumor recurrence following an R0N0 resection of pCCA. Methods pCCA patients undergoing curative-intent resection with R0 and N0 tumor were identified from an international multi-institutional database. A pathology-based risk score was developed to predict recurrence-free survival (RFS). In addition, genomic profiling was performed in a subset of patients to evaluate the prognostic relevance of genetic alterations. Results Among 298 patients with resected R0N0 pCCA, 131 (44.0%) developed disease recurrence. Multivariable analysis identified advanced AJCC T category (T2b or T3/T4), perineural invasion, and poor tumor differentiation as independent predictors of inferior RFS. Based on these factors, a three-variable pathology-based risk score stratified patients into low-, intermediate-, and high-risk groups with corresponding 3-year RFS of 85%, 31%, and 27%, respectively. Both intermediate- and high-risk patients had worse RFS versus low-risk patients (high-risk vs. low-risk: median RFS, 15.0 vs. 92.9 months; intermediate-risk vs. low-risk: median RFS, 23.0 vs. 92.9 months; both p < 0.001). KRAS mutations occurred in 29% of profiled patients, which was associated with reduced RFS (mutant vs. wild-type KRAS: median RFS, 11.0 vs. 24.0 months, p = 0.011). Conclusions Recurrence risk among patients with R0N0 pCCA was heterogeneous. The proposed risk score stratified patients into markedly different risk categories relative to recurrence, which may help guide utilization of adjuvant therapy as well as surveillance in the postoperative setting.

BACKGROUND/AIMS:Biliary complications are a leading cause of morbidity after liver transplantation, but can be reduced using real-time assessment of the biliary tree. This study described a novel technique for performing ex vivo cholangioscopy during cold static storage and normothermic machine perfusion (NMP) to assess the biliary tree before liver transplantation. METHODS:Human donor livers, which were considered unsuitable for transplantation, were perfused at 36ºC using a modified commercial ex vivo perfusion system. Ex vivo cholangioscopy was performed using a SpyGlass Discover system. Cholangioscopy was performed during cold static storage and after 12 hours in NMP. Bile duct biopsies and confocal microscopy were performed. RESULTS:Ex vivo cholangioscopy was performed on eight grafts. During cold static storage, luminal debris was visualized throughout the biliary tree. After 12 hours of reperfusion, the bile ducts appeared hyperemic, heterogeneous, and mottled. Confocal microscopy confirmed perfusion of biliary microvasculature. CONCLUSIONS:We describe the first use of ex vivo cholangioscopy to assess the biliary tree before liver transplantation. This real-time technique can be used to assess biliary trees during cold static storage and NMP. In addition, cholangioscopy-based interventions can be used to better assess intrahepatic bile ducts.

Biliary anatomy is highly variable, and aberrant anatomy increases the risk of bile duct injury during cholecystectomy. Awareness of anatomical variation is essential to prevent avoidable complications. A 37-year-old male with acute gallstone pancreatitis underwent laparoscopic cholecystectomy. Anatomy on intra-operative cholangiography was unclear, prompting conversion to open, where repeat cholangiogram showed the common hepatic duct draining into the gallbladder infundibulum. A subtotal cholecystectomy preserving the infundibulum was performed. The patient developed a bile leak requiring re-look laparotomy and hepaticojejunostomy on post-operative day 5, later revised after anastomotic breakdown. He recovered fully and was well at 1-month follow-up. Cholecystohepatic duct is a rare biliary anomaly that is difficult to detect pre-operatively. Magnetic resonance cholangiopancreatography may help, but is not routine, so a high index of suspicion is crucial. Intra-operative cholangiography and a critical view of safety help to prevent injury. Surgical management depends on anatomy, but generally hepaticojejunostomy is recommended.

INTRODUCTION:For many patients, liver transplantation (LT) is not feasible due to a shortfall of suitable organs. In Australia, almost all grafts come from deceased donors, a pool not easily expanded, and many potentially useable grafts are declined for viability concerns. Despite this, referral utilisation is incompletely understood. The objective of this paper was to characterise deceased donor liver utilisation and referral patterns at a major Australian LT unit. METHODS:All deceased donor referrals made to the Australian National Liver Transplantation Unit (ANLTU) from 2014 to 2024 were included. The primary endpoint was the utilisation rate of referrals made to the ANLTU. Secondary endpoints included the effect of referring hospital location on utilisation, reason for decline and donor characteristics. RESULTS:A total of 1649 referrals were included. During the study period, out-of-network referral volume increased significantly, from 23 to 77 annually (p = 0.044). Overall, utilisation fell from 61.3% to 43.2% (p = 0.045), due to falling utilisation of out-of-network referrals. In-network donation after neurological determination of death (DNDD) and circulatory determination of death (DCDD) referral utilisation was stable at 65.3% (p = 0.979) and 30.0% (p = 0.621), respectively. In-network referrals were increasingly declined due to an absence of a suitable potential recipient (p = 0.003) and out-of-network due to the graft being unsuitable for the urgently listed patient (p = 0.038). CONCLUSION:Utilisation of in-network referrals has remained unchanged since 2014. Out-of-network referral volume is increasing, with reduced utilisation of grafts amongst this cohort. Techniques to improve organ utilisation will be critical to expand access to LT in Australia.

Pancreatic surgery is a technically demanding field associated with frequent morbidity, with pancreatic fistula representing the dominant driver of major complications in pancreaticoduodenectomy (PD). Although refinements in operative technique, perioperative management, and institutional systems have contributed to incremental improvements, the overall incidence of clinically relevant complications has remained largely unchanged over recent decades. This narrative review provides a comprehensive overview of current strategies aimed at reducing morbidity and mortality after pancreaticoduodenectomy, focusing on modifiable technical, pharmacological, nutritional, and systems-based interventions, whilst acknowledging the underlying biological determinants that remain difficult to alter. This review synthesises contemporary evidence on fistula risk modelling, anastomotic reconstruction, and adjunctive operative techniques. The role of pharmacological interventions is examined alongside an evaluation of perioperative nutritional optimisation and enhanced recovery frameworks. Systems-based strategies such as centralisation, failure-to-rescue performance, protocolised pathways, and algorithm-driven postoperative surveillance are highlighted as emerging areas with substantial potential to impact survival independently of complication rates. Finally, this review explores future directions, including radiomics-based risk stratification, intraoperative imaging, and tailored postoperative care. Together, these domains provide a platform for reducing complication severity, standardising postoperative care, and ultimately improving patient outcomes. By integrating these perspectives, this review aims to present a comprehensive and in-depth narrative of how to reduce complications in pancreas surgery. Overall, this narrative review proposes that meaningful improvements in outcomes after PD likely do not arise from the elimination of complications altogether, but rather from improved prediction, prevention where possible, and critically, more effective systems of care that reduce the severity and consequences of complications when they occur.

Background: Clinical staging of American Joint of Cancer Committee (AJCC) tumor-node-metastasis (TNM) system for intrahepatic cholangiocarcinoma (ICC) is under ongoing debate. Perineural invasion (PNI) represents an adverse prognostic factor for ICC. The aim of this study was to propose a new T category for early-staged ICC by incorporating PNI. Methods: Patients undergoing curative-intent surgical resection for ICC were identified from an international multi-institutional database. T category for early-staged ICC was modified based on combination of tumor size, vascular invasion and PNI status. Disease-free survival (DFS) was utilized to assess prognostic differences among redefined stage groups. Results: A total of 307 stage T1-2 ICC patients with solitary mass-forming tumor were included for analysis. Multivariable Cox regression analysis identified that large tumor size (>5 cm) and PNI were independently associated with worse DFS. A modified AJCC T category (mT) was proposed: mT1 consists of tumor sizing <= 5 cm; mT2a consists of tumor sizing >5 cm; mT2b consists of tumor with vascular invasion and/or PNI. Among the updated mT2b group, 19 patients had concomitant vascular invasion and PNI, while 35 and 20 patients had vascular invasion alone and PNI alone, respectively. Patients with mT2b showed significantly inferior DFS than mT1 (25.0 months vs. not reached, P=0.001), yet an almost identical DFS outcome as mT2a (25.0 vs. 18.0 months, P=0.94). Conclusions: The new mT category better stratifies prognostic groups for early-staged ICC in comparison to the current system. These findings should be validated and considered in the future update of staging criteria for ICC.

BACKGROUND:Recurrence is a major driver of poor long-term outcomes after curative-intent resection for intrahepatic cholangiocarcinoma (iCCA), yet the association between postoperative pathology, first recurrence patterns, and post-recurrence outcomes remains unclear. METHODS:Patients who underwent curative-intent resection for iCCA (2000-2023) were identified from an international multi-institutional database. First recurrence patterns were classified as intrahepatic-only, extrahepatic-only, or combined intrahepatic and extrahepatic recurrence. Multivariable analyses assessed associations between postoperative pathological features, first recurrence patterns, post-recurrence survival (PRS), and post-recurrence curative-intent treatment. RESULTS:Among 1328 patients, 763 patients (57.5%) developed a recurrence; 717 patients had a classifiable first recurrence pattern (381 patients developed intrahepatic-only recurrence, 171 patients developed extrahepatic-only recurrence, and 165 patients developed combined intrahepatic and extrahepatic recurrence). Three or more metastatic lymph nodes (adjusted OR (aOR) 3.47 (95% c.i. 1.56 to 7.72)) and microvascular invasion (aOR 2.49 (95% c.i. 1.61 to 3.85)) were associated with higher odds of combined recurrence compared with intrahepatic-only recurrence, whereas perineural invasion (aOR 2.24 (95% c.i. 1.35 to 3.71)) and the absence of pathological nodal evaluation (aOR 2.04 (95% c.i. 1.24 to 3.36)) were associated with extrahepatic-only recurrence. Compared with intrahepatic-only recurrence, combined recurrence was associated with worse PRS (adjusted HR 1.63 (95% c.i. 1.29 to 2.06)) and lower odds of receiving curative-intent treatment (aOR 0.14 (95% c.i. 0.06 to 0.29)). CONCLUSION:Pathological nodal burden and invasive tumour features were associated with distinct first recurrence patterns after iCCA resection. Combined recurrence, more common with ≥3 metastatic lymph nodes or microvascular invasion, was associated with worse PRS and lower receipt of curative-intent treatment. Among patients who develop recurrence, pathological prognostic factors available after surgery may help characterize first recurrence patterns and inform risk-adapted postoperative surveillance.

BACKGROUND:This cross-sectional study evaluated risk-adjusted cumulative sum (RA-CUSUM), a tool for real-time monitoring of perioperative outcomes, in liver surgery across an international multicenter cohort. METHODS:Patients undergoing curative-intent hepatectomy for hepatocellular carcinoma (31%), intrahepatic cholangiocarcinoma (29.7%), or colorectal liver metastases (39.3%) across 25 centers (2000-2023) were analyzed. RA-CUSUM curves were generated for operative time, intraoperative blood loss, major complications (Clavien-Dindo ≥ III), and length of stay (LOS). Mixed-effects models were used for overall curves and center-specific regressions for institutional analyses. Secondary outcomes included R1 resection and 1-year recurrence comparing the first 50 and subsequent cases at each center. RESULTS:Among 5880 cases 38.2% were major hepatectomies, while 15.1% were minimally invasive. Median operative time was 240 min (IQR 150-356), median blood loss 300 mL (IQR 100-600), and median LOS 9 days (IQR 6-14). Major complications occurred in 35.1% of patients. RA-CUSUM curves demonstrated a biphasic pattern, with deterioration coinciding with the spread of minimally invasive surgery, and subsequent improvement. Center-level curves revealed marked heterogeneity. Secondary outcomes demonstrated no uniform early-period disadvantage. CONCLUSIONS:RA-CUSUM offers a real-time visualization of surgical performance and can guide quality review and support targeted quality-improvement initiatives in liver surgery units.

BACKGROUND:Accurate preoperative risk stratification remains essential for patients undergoing curative-intent hepatectomy for intrahepatic cholangiocarcinoma (iCCA) or hepatocellular carcinoma (HCC). Although the albumin-bilirubin (ALBI) score and AST-to-platelet ratio index (APRI) reflect hepatic reserve and fibrosis burden, respectively, their complementary value for predicting liver-related complications across primary liver malignancies remains poorly defined. METHODS:A retrospective multi-institutional cohort study included 2668 patients who underwent curative-intent hepatic resection for iCCA or HCC (2000-2023). Multivariable logistic regression evaluated associations of ALBI and APRI with liver-related complications, post-hepatectomy liver failure (PHLF), and major complications. Discrimination was assessed using the area under the receiver operating characteristic curve (AUC) with bootstrap internal validation. RESULTS:Among 2668 patients, 392 (14.7%) developed liver-related complications. Both ALBI (OR 1.65, 95% CI 1.28-2.12) and APRI (OR 1.18, 95% CI 1.05-1.33) were independently associated with liver-related complications. The combined model achieved an AUC of 0.740 (optimism-corrected 0.733). ALBI and APRI also demonstrated differential associations across endpoints, with APRI more strongly associated with PHLF and ALBI more strongly associated with major complications. DISCUSSION:Preoperative ALBI and APRI were independently associated with liver-related complications after hepatectomy for iCCA and HCC, reflecting hepatic reserve and fibrosis-related injury.

INTRODUCTION:We sought to evaluate the impact of severe postoperative complications on recurrence-free survival (RFS) after curative-intent resection for pCCA with particular attention to tumor biology. METHODS:An international multi-institutional database was queried to identify patients who underwent curative-intent liver resection for pCCA between 2000 and 2023. Patients who died within 90 days of surgery were excluded. Severe complications were defined as Clavien-Dindo grade ≥ III. RESULTS:Among 453 patients, the median age was 67 years (IQR, 57-74), 62.3% were male, 29.3% had CA19-9 ≥400 U/mL, and 36.6% experienced severe postoperative complications. Overall, 3-year RFS was worse among patients with severe complications versus those without (26.7% vs 30.7%; p = 0.044). This association was more pronounced among patients with CA19-9 <400 U/mL (25.4% vs 32.9%; p = 0.014), whereas no difference was observed among patients with CA19-9 ≥400 U/mL (28.3% vs 24.9%; p = 0.88). On multivariable analysis, severe complications remained independently associated with worse RFS among patients with CA19-9 <400 U/mL (HR 1.39, 95% CI 1.03-1.88; p = 0.03), but not among individuals with CA19-9 ≥400 U/mL (HR 0.78, 95% CI 0.48-1.28; p = 0.32). On sensitivity analyses using a Fine-Gray competing risk model, severe postoperative complications were not independently associated with recurrence in either subgroup. CONCLUSIONS:The association between severe postoperative complications and long-term outcomes appeared more evident among patients with more favorable tumor biology.

Background: The Prognostic Nutritional Index (PNI), which reflects both nutritional status and systemic inflammation, may have prognostic value. The impact of PNI among patients with intrahepatic cholangiocarcinoma (ICC) remains unclear. We sought to evaluate the prognostic impact of PNI and other nutritional markers among patients undergoing curative-intent resection for ICC. Methods: Patients who underwent curative-intent hepatectomy for ICC between 2000 and 2023 were identified from a large, international, multi-institutional database. Multivariable Cox regression analysis was performed to assess the association between nutritional indices and overall survival (OS). Results: Among 914 eligible patients, 178 (19.5%) had low PNI (<45), while 736 (80.5%) had high PNI (>= 45). On multivariable analysis, PNI <45 was independently associated with worse OS [hazard ratio (HR) 1.39, 95% confidence interval (CI): 1.10-1.76]. Patients with high PNI (>= 45) had longer OS vs. individuals with low PNI (<45) (median OS: 52.0 vs. 31.6 months, P<0.001). Notably, patients with low PNI and T1/2 disease had median OS comparable to individuals with high PNI and T3/4 disease (median OS: low PNI & T1/2 35.1 months vs. high PNI & T3/4 29.8 months); the overall comparison across the four strata was significant (global log-rank P<0.001). Conclusions: Low PNI was independently associated with poor OS following curative-intent resection for ICC. These findings highlight the value of preoperative nutritional assessment and support the potential role of targeted perioperative interventions to improve outcomes in this high-risk population.

Background/purpose Prior abdominal surgery is associated with increased complexity of liver transplantation (LT), but this represents a heterogenous cohort. We sought to quantify the intraoperative impact of prior abdominal surgery in LT. Methods Our prospective LT database (2012-2023) was analysed, comparing patients based on location of prior surgery (re-transplant, hepatobiliary, other abdominal) and method of entry (open, laparoscopic). Primary outcomes were operating time (OT) and transfusion requirements (PC). Statistical analysis included ANOVA and Chi-square tests (p<0.05) and multivariate regression to control for covariates. Results 771 patients were included. Mean operative time for patients without prior abdominal surgery was 33.05±111min, significantly lower than those who had undergone re-transplantation (435±150.5, p<0.001), hepatobiliary (386.5±119.8, p<0.001) or any open abdominal surgery (391.4±124.4, p=0.013). Transfusion requirements without prior surgery were 5.24±4.9units, lower compared to re-transplantation (12.49±13.7, p<0.001), hepatobiliary (7.57±5.2, p<0.001) or open surgery (8.49±10.2, p<0.001). No similar associations were observed in patients who had previous laparoscopic (OT 355.7±121.8; PC 5.81±6.0, p>0.05) or non-RUQ surgery (OT 360.3±117.8; PC 6.02±5.6, p>0.05). Conclusions Patients with prior re-transplant, hepatobiliary and open surgery are associated with increased operating time and transfusion, whilst laparoscopic approaches did not worsen outcomes. Planning for these high-risk patients necessitates detailed pre-operative surgical assessment.