BACKGROUND:ABO-incompatible (ABOi) deceased donor liver transplantation (DDLT) is seldom used due to concerns regarding postoperative outcomes, derived from predominantly older cohorts with small sample sizes. The aim of this study is to assess the impact of ABO incompatibility on outcomes of DDLT in a large, contemporary cohort. METHODS:Adult DDLT patients were included from the Scientific Registry of Transplant Recipients (SRTR) database who underwent transplant from 2004 to 2024. Demographics and complications were compared between ABOi and ABO-compatible (ABO-c) cohorts. Multivariate Cox proportional hazards models were generated to assess the impact of ABO incompatibility on 5-year outcomes. RESULTS:A total of 125,997 patients were included, with 1371 (1.1%) being ABOi. The ABOi cohort tended to be younger (53.0 ± 11.9vs54.5 ± 11.0,p < 0.001) but with severe disease requiring preoperative ICU care (24.4%vs14.1%,p < 0.001) and with higher MELD scores (25.6vs21.9,p < 0.001). Multivariate survival modelling showed that ABOi is not associated with graft loss (defined as mortality or retransplant; aHR 1.00, 95%CI 0.84-1.18) or mortality (aHR 0.83, 95%CI 0.68-1.01), but with increased likelihood of retransplant (aHR 2.08, 95%CI 1.42-3.06). Results were similar when A2 to O incompatible transplants were excluded. CONCLUSIONS:ABOi DDLT is associated with increased likelihood of retransplant but did not show an association with mortality, supporting its use in highly selective unwell patients requiring urgent transplant.

Background Minimally invasive surgery (MIS) is often advocated for patients with obesity as a safer alternative. MIS pancreaticoduodenectomy is becoming increasingly popular, however without consistent benefits in all cohorts, including the elderly and low-volume centres. This study aims to compare the post-operative outcomes of MIS versus open pancreaticoduodenectomy in a growing population, namely, obese patients. Methods Patients with severe obesity or a body mass index (BMI) ≥ 35 kg/m2 undergoing a pancreaticoduodenectomy from the National Surgical Quality Improvement Program database were included. Association of MIS with 30-day serious complications and mortality was analyzed using multivariable logistic regression and propensity matching analysis. Results In this study, 1859 patients were included, with 1785 undergoing open and 74 undergoing MIS pancreatoduodenectomy. Multivariable analysis did not show an association between a MIS approach and 30-day serious complications [OR 1.11, p = 0.760] or mortality [OR 2.54, p = 0.176]. Results were similar with the propensity matched analysis which, showed that MIS had longer operative durations [86.6 minutes, p < 0.001)], but with similar rates of serious complications, Comprehensive Complication Index (CCI) scores, and mortality. Conclusion For patients with severe obesity, this study demonstrates that MIS pancreatoduodenectomy does not significantly decrease the morbidity or mortality within the confinements of our population size. Future studies should assess which patient cohorts are more likely to benefit from MIS and the impact of the learning curve.

Background: Despite ongoing efforts to improve the pancreaticoduodenectomy technique and perioperative care, surgical site infection (SSI) remains a contributor to morbidity. Efforts to reduce SSI include the use of negative pressure wound therapy (NPWT), but studies and meta-analyses have been met with conflicting results. We aimed to provide an up-to-date large-scale cohort study to assess the impact of NPWT on SSIs. Methods: Utilizing the National Surgical Quality Improvement Program database, we included patients undergoing a pancreaticoduodenectomy between 2017 and 2021 and divided patients into the NPWT and non-NPWT cohorts. A bivariate analysis was performed to compare baseline characteristics and complication rates between the cohorts. Multivariate logistic regression analysis was performed to assess the independent effect of NPWT on 30-day serious complication, 30-day mortality, and the development of deep or superficial SSI. A priori sensitivity analyses were performed in high-risk and malignancy cohorts. Results: Of the 14,044 included patients, 1689 (12.0%) patients had a prophylactic NPWT device, while 12,355 (88.0%) did not. Patients were more likely to have NPWT if they had higher ASA scores, had diabetes, were dialysis-dependent, or had a hard pancreas, but they were less likely if they were a smoker, had steroid use, or had a bleeding disorder. Most complications occurred similarly between the two cohorts, including superficial and deep SSI, but NPWT patients had a longer length of stay (10.4 d vs. 9.5 d, p < 0.001) and higher organ space SSI (22.6% vs. 17.4%, p < 0.001). Following multivariable modeling to control for demographic differences, NPWT was not independently associated with a difference in likelihood of SSI (aOR 0.94, p = 0.691) or serious complications (aOR 0.958, p = 0.669). Furthermore, the sensitivity analyses of both high-risk and malignant subgroup also did not see an independent association of NPWT on the rate of SSI (aOR 0.98, p = 0.898 and 0.96, p = 0.788, respectively). Conclusion: NPWT is used infrequently and is not significantly associated with improved outcomes including in the high-risk or malignant subgroups based on multivariable analysis for surgical site infections nor did it improve the outcomes of 30-day serious complications in these subgroups. Considering this and other studies showing the limited benefit of NPWT in all-comers and in high-risk cohorts, it remains unclear whether NPWT offers benefits following PD.

Background: Primary sclerosing cholangitis (PSC) accounts for 10–15% of liver transplants but is the leading cause of retransplant. This study evaluates whether PSC patients have different survival and graft outcomes when receiving grafts from donors after brain death (DBD) versus circulatory (DCD) death. Methods: Using the SRTR database (2004–2024), we compared PSC patients receiving DCD vs. DBD grafts. Demographics and outcomes including graft loss, mortality, and retransplant were analyzed using multivariable logistic and Cox regression, along with propensity-matched analysis. Results: Among 5762 PSC patients, 391 (6.8%) received DCD grafts. Patients receiving DCD grafts were older but had lower MELD scores (19 vs. 22; p < 0.001) and were less often functionally dependent (11.3% vs. 24.4%; p < 0.001). Multivariable Cox regression demonstrated that receipt of a DCD graft was independently associated with time to graft loss (HR 1.59; CI 1.10–2.31; p = 0.013. Similarly, DCD graft receipt significantly increased the likelihood of requiring retransplant (HR 3.25; CI: 1.93–5.46; p < 0.001) but did not increase the likelihood of mortality. Propensity matched analysis further supported these finding with significantly higher graft loss with DCD grafts at one and two years and higher retransplant rates at all time points including 5-years (+7.9%, CI 4.4 to 11.4%; p < 0.001). Conclusions: DCD grafts in PSC patients are linked to worse graft survival and higher retransplant rates. They may be best suited for older, lower-MELD patients, but further studies on perfusion strategies are needed.

OBJECTIVE:To evaluate risk of severe hypoglycemia after total pancreatectomy (TP). BACKGROUND:Historically, TP was feared due to loss of insulin and counter-regulatory hormones, as well as the risk of severe hypoglycemic events (SHE). While TP with islet auto-transplant (TPIAT) can preserve endocrine function, past studies reported 41% SHE incidence post-operatively. Advancements in insulin therapies and continuous glucose monitors (CGMs) have likely improved outcomes but are understudied in this population. METHODS:This single center study analyzed TP patients from 2009-2024. CGMs (Dexcom G7) were provided for the study if patients did not have one. Demographics, survival, emergency department visits, and glycemic control were assessed. RESULTS:Among 147 TP cases, 76 underwent TP alone and 71 TPIAT. In the TP-alone patients, two deaths (2/76; 2.63%) occurred due to hypoglycemia. Pre-operatively, TP-alone patients had higher HbA1c (7.1±2.2%) than TPIAT patients (5.9±1.3%; P<0.001). In the first month post-operatively, TP-alone patients had higher HbA1c than TPIAT-insulin dependent patients, but no difference over 10 years. Hypo/hyperglycemia-related hospital visits, median time in target range (TP: 53.5%, IQR: 36.5-68.5 vs. TPIAT insulin-dependent: 59.0%, IQR: 43.3-67.5), and glycemic variability (coefficient of variation; 31.3%, IQR 28.3-35.0 vs 32.3%, IQR 28.7-35.5) were similar between TP-alone and TPIAT-insulin dependent groups. In 14 days of CGM capture, no severe hypoglycemia was observed in TP-alone patients (<3.0 mmol/L). CONCLUSIONS:Advancements in insulins and CGMs provide acceptable outcomes after TP without supplemental islet transplantation, and lower risk of SHE than previously reported. This encouraging data may aid surgical decision-making and patient selection for surgery.

BACKGROUND:Detailed data on the relation of post-operative complications with clinical outcomes after simultaneous pancreas-kidney (SPK) transplantation is lacking. AIM:To compare Clavien-Dindo classification (CDC) and comprehensive complication index (CCI) in predicting outcomes after SPK. METHODS:Data for patients undergoing SPK between 1999-2019 were analyzed. Information on recipients' baseline characteristics, peri-operative management and post-operative complications were collated. Length of hospital stay (LOS) was the primary study outcome, and the associations with CDC and CCI were evaluated using Spearman's (ρ) correlation coefficients. RESULTS:In the study period, data were available for 128 patients (female n = 44, 34.4%). Sixty-nine patients had at least one complication with the highest CDC grade of I, II, III, and IV in 8 (6.3%), 22 (17.2%), 32 (25%), and 7 (5.5%) patients, respectively. The mean LOS was 21.4 ± 17.7 days. Both classification systems were correlated with LOS, yet CCI was stronger (Spearman's ρ: 0.694 vs 0.602, P < 0.001). Female patients (P = 0.019) and patients with pre-transplant cardiovascular events (P = 0.02) had longer LOS. After adjusted multivariable analysis, the link between LOS and both the CDC and CCI remained relevant. CCI had a superior fit compared to CDC (r 2 = 0.729 vs r 2 = 0.481), with every 10 CCI points being associated with a 5.27 day (P < 0.001) increased LOS. CONCLUSION:This study showed that the CCI was better linked with LOS compared to CDC and might represent a useful score to evaluate the overall burden of postoperative complications in patients undergoing SPK.

Background: Total pancreatectomy (TP) offers a surgical option for refractory pancreatitis, yet confers substantial long-term morbidity associated with resultant diabetes. While total pancreatectomy with islet autotransplantation (TPIAT) offers an intuitive solution, data evaluating its safety have been limited to single-center studies. The aim of this study is to evaluate whether the addition of islet autotransplantation to TP confers additional post-operative morbidity within the 30-day post-operative period. Methods: This is a retrospective cohort study of prospectively collected cases from the National Surgical Quality Improvement Program (NSQIP) database. Cases of TP with or without islet autotransplantation from 2016 to 2021 were included. Baseline demographics, and a comprehensive list of 30-day postoperative outcomes were evaluated. Multivariable logistic regression models were constructed to evaluate the impact of each factor on 30-day complications. Results: A total of 584 cases were included with 171 (29.2 %) patients undergoing TPIAT. TPIAT patients were younger (58.8 vs. 39.5; p < 0.0001), and had lower incidences of pre-existing diabetes (41.4 % vs. 19.9 %; p < 0.0001) and hypertension (48.2 % vs. 24.6 %; p < 0.0001). TPIAT cohort had longer length of stay (10.3 days vs.12.2 days; p = 0.0006). There was no difference in overall rates of serious complications between the two cohorts (50.1 % vs. 45.0 %; p = 0.263). After adjusting for demographic differences between cohorts using multivariable logistic regression models, TPIAT was not associated with serious complications (OR 0.71; p = 0.168) compared to TP alone. Conclusion: The results from this study suggest that TPIAT does not appear to be associated with increased 30-day morbidity, and should be considered in patients to mitigate the long-term morbidity associated with diabetes mellitus post TP. (c) 2024 The Authors. Published by Elsevier B.V. on behalf of IAP and EPC. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

To evaluate risk of severe hypoglycemia after total pancreatectomy (TP). Historically, TP was feared due to loss of insulin and counter-regulatory hormones, as well as the risk of severe hypoglycemic events (SHE). While TP with islet auto-transplant (TPIAT) can preserve endocrine function, past studies reported 41% SHE incidence post-operatively. Advancements in insulin therapies and continuous glucose monitors (CGMs) have likely improved outcomes but are understudied in this population. This single center study analyzed TP patients from 2009-2024. CGMs (Dexcom G7) were provided for the study if patients did not have one. Demographics, survival, emergency department visits, and glycemic control were assessed. Among 147 TP cases, 76 underwent TP alone and 71 TPIAT. In the TP-alone patients, two deaths (2/76; 2.63%) occurred due to hypoglycemia. Pre-operatively, TP-alone patients had higher HbA1c (7.1±2.2%) than TPIAT patients (5.9±1.3%; P<0.001). In the first month post-operatively, TP-alone patients had higher HbA1c than TPIAT-insulin dependent patients, but no difference over 10 years. Hypo/hyperglycemia-related hospital visits, median time in target range (TP: 53.5%, IQR: 36.5-68.5 vs. TPIAT insulin-dependent: 59.0%, IQR: 43.3-67.5), and glycemic variability (coefficient of variation; 31.3%, IQR 28.3-35.0 vs 32.3%, IQR 28.7-35.5) were similar between TP-alone and TPIAT-insulin dependent groups. In 14 days of CGM capture, no severe hypoglycemia was observed in TP-alone patients (<3.0 mmol/L). Advancements in insulins and CGMs provide acceptable outcomes after TP without supplemental islet transplantation, and lower risk of SHE than previously reported. This encouraging data may aid surgical decision-making and patient selection for surgery.

Guidelines for managing hepatic artery thrombosis (HAT) and stenosis (HAS) after pediatric liver transplantation (pLT) are lacking, with heterogeneous local practices. This study aims to evaluate management practices for HAT and HAS after pLT. An online and paper-based survey was sent to 36 international pLT centers. The survey included 36 questions covering center experience, screening protocols, diagnostic criteria, preventive management, post-procedural care, and follow-up. Treatment strategies were explored through hypothetical case scenarios categorized by early (≤14 d after pLT) and late onset complications (>14 d after pLT). Responses from 36 centers showed that 60% applied interrupted sutures and 76% used a surgical loupe during transplantation. In addition, 89% followed a specific anticoagulation protocol after uncomplicated pLT. All centers initiated Doppler ultrasound (DUS) within 24 hours after pLT, with 60% conducting it daily during the first week. Immediate re-transplantation was preferred for early HAT with pediatric acute liver failure (PALF) (61% vs. 11% for non-PALF, p <0.001), and surgical revascularization was more frequently chosen for non-PALF cases (51% vs. 24% for PALF, p <0.001). Endovascular therapy was selected in 35% of cases for both late HAT and HAS, with conservative management chosen in 51% for late HAT and 61% for late HAS (all p <0.001, compared to early cases). Internationally, there is agreement on the importance of early DUS screening in current management practices. Immediate re-transplantation was preferred for early HAT with PALF, while surgical revascularization was favored for non-PALF cases. Conservative management and endovascular therapy emerged as potential strategies for late-onset cases. This worldwide survey on real-world practice provides a basis for developing and implementing guidelines.

BACKGROUND:Wound protectors (WPs) have been shown to decrease postoperative wound complications, yet limited data exist supporting WP for pancreaticoduodenectomies, with limited uptake in practice. We evaluated the effect of WP in pancreaticoduodenectomies on surgical site infections (SSIs) and serious complications. METHODS:Utilizing the National Surgical Quality Improvement Program database, we included patients undergoing pancreaticoduodenectomy between 2017 and 2021. Baseline demographics and complications were compared between WP and no WP cohorts. Multivariate logistic regression was performed to identify the effect of WP use on 30-day complications and factors associated with WP use. RESULTS:Of 20 960 patients, 6167 (29.4%) used a WP. WPs were more commonly used in lower ASA classes, more comorbid patients, and preoperative weight loss. WP use was associated with increased operative time but decreased length of stay, SSIs, organ space infection, pancreatic fistula, reoperation, and serious complication. WP was independently associated with decreased serious complication (aOR 0.80, p < 0.001) and SSI (aOR 0.57, p < 0.001). Factors associated with increased likelihood of WP use include preoperative weight loss, broad-spectrum antibiotic use, absence of bleeding disorder and firmer pancreatic texture. CONCLUSION:WP use during pancreaticoduodenectomy is associated with decreased number of postoperative complications and SSI. Future prospective randomized studies should assess cost-benefit and barriers to use to increase uptake of WP use.

Islet transplantation (ITx) is an established treatment for recurrent, severe hypoglycemia in type 1 diabetes, however, requires lifelong immunosuppression (IS) which can be nephrotoxic. We conducted a risk regression to identify factors associated with progression to Stage 3 CKD (S3CKD) or worse post-ITx. We used data from adults undergoing ITx alone at the University of Alberta Hospital between March 11 1999 and Oct 1 2019 with >1 year follow up. IS included tacrolimus and sirolimus/mycophenolate. We identified episodes of irreversible S3CKD as eGFR <60 ml/min/1.73m2 for ≥90d in addition to a final 12m average eGFR below threshold. We conducted multivariable competing risk (death) regression with the covariates: baseline eGFR, age at first ITx, diabetes duration, total ITx count, mean tacrolimus trough levels in year 1 post-ITx, number of acute kidney injury (AKI) events in year 1 post-ITx, sex, baseline hypertension and sirolimus exposure. We identified 199 adults (41% M followed for a median 76.1m [IQR 38.0-131.6]), of which 47.7% progressed to S3CKD within a median 28m [IQR 9-57]. Female sex and more AKI events substantially increased the risk of progression to S3CKD (HR 1.50, [95% CI 1.31,1.80, p =0.004; HR 1.21, [95% CI 1.02, 1.45, p=0.028] respectively). Older age at first-ITx, lower baseline eGFR and longer diabetes duration had modest effect of significance on the risk of progression. Mean tacrolimus level in the first year post-ITx, number of ITx, baseline hypertension and exposure to sirolimus were not significant predictors for the risk of progression to S3CKD. No sex differences were found in risk for Stage 4 or 5 CKD. IS may put female ITx recipients at greater hazard of progressing to S3CKD, independently of other potential risk factors. Further study is required to elucidate this association, which could translate into sex-specific strategies to manage IS post-ITx. Effective IS regimens without nephrotoxicity remain an important goal. Disclosure A.L.J. Carr: None. B.A. Marfil-Garza: None. A. Lam: None. B.L. Anderson: None. D. O'Gorman: None. T. Kin: None. D. Bigam: None. A. Shapiro: Consultant; Vertex Pharmaceuticals Incorporated, Betalin Therapeutics, Hemostemix Inc, ViaCyte, Inc., Aspect Biosystems. P.A. Senior: Consultant; Abbott, Bayer Inc., Dexcom, Inc., Eli Lilly and Company, GlaxoSmithKline plc, Insulet Corporation, Novo Nordisk Canada Inc., Sanofi, Vertex Pharmaceuticals Incorporated. Speaker's Bureau; Abbott, Dexcom, Inc., Insulet Corporation, Novo Nordisk Canada Inc. Research Support; Novo Nordisk Canada Inc.

Introduction Hepatic artery complications (HACs), such as a thrombosis or stenosis, are serious causes of morbidity and mortality after paediatric liver transplantation (LT). This study will investigate the incidence, current management practices and outcomes in paediatric patients with HAC after LT, including early and late complications.Methods and analysis The HEPatic Artery stenosis and Thrombosis after liver transplantation In Children (HEPATIC) Registry is an international, retrospective, multicentre, observational study. Any paediatric patient diagnosed with HAC and treated for HAC (at age <18 years) after paediatric LT within a 20-year time period will be included. The primary outcomes are graft and patient survivals. The secondary outcomes are technical success of the intervention, primary and secondary patency after HAC intervention, intraprocedural and postprocedural complications, description of current management practices, and incidence of HAC.Ethics and dissemination All participating sites will obtain local ethical approval and (waiver of) informed consent following the regulations on the conduct of observational clinical studies. The results will be disseminated through scientific presentations at conferences and through publication in peer-reviewed journals.Trial registration number The HEPATIC registry is registered at the ClinicalTrials.gov website; Registry Identifier: NCT05818644.

BACKGROUND:Recurrent disease after liver transplant is well recognized for many diseases. Metabolic dysfunction-associated steatotic liver disease (MASLD) and steatohepatitis (MASH) are leading indications for liver transplant, and there is scarce knowledge about recurrence-related end outcomes such as retransplant and mortality. This project aims to assess the proportion of patients transplanted for MASH who develop recurrent disease and adverse clinical outcomes. METHODS:A systematic review and pooled proportions meta-analysis was performed by searching the following databases: MEDLINE, Embase, Scopus, Web of Science Core Collection, and Cochrane Library. Inclusion criteria were studies discussing adult patients with liver transplants secondary to MASH or presumed MASH with recurrent disease-related outcomes. Outcomes were assessed in time frames from <6 mo to ≥5 y. RESULTS:Of 5859 records, 40 were included (16 157 patients). Recurrent MASLD and MASH (28 studies each) occurred in frequencies of 35%-49% and 11%-24%, respectively. Fibrosis occurred in 4%-25% (13 studies). Recurrent disease-related cirrhosis (13 studies), graft failure (8 studies), and retransplant (9 studies) occurred in 0%-2%, 3%-9%, and 0%-1%, respectively. Recurrent disease-related hepatocellular carcinoma (1 study) and mortality (17 studies) both had a prevalence of 0%. Studies were of moderate or high quality using the Methodological Index for Non-Randomized Studies tool. CONCLUSIONS:Recurrent MASLD and MASH after liver transplant occur frequently, but adverse clinical outcomes due to disease recurrence are infrequent, maybe due to insufficient data on long-term follow-up. Long-term outcomes after transplantation for MASLD appear favorable; however, identifying those more likely to have progressive recurrent disease leading to adverse clinical outcomes may allow for pre- and posttransplant interventions to improve outcomes further.