INTRODUCTION:Despite the broader adoption of minimally invasive liver surgery (MILS) for adults, its application in the pediatric population has been mainly documented in single-center reports. We aimed to summarize the current state of evidence of MILS in children. METHODS:We systematically reviewed PubMed, Scopus, Web of Science, and Cochrane Library databases according to the PRISMA statement for children (<18 years) undergoing MILS (end-of-search date: 03/03/2024). The National Cancer Database (NCDB) was queried for children (<18 years) undergoing MILS (2010-2021). RESULTS:Forty-one articles reporting on 211 patients were included. The approach was laparoscopic in 91.5%, robotic in 5.7%, and hand-assisted 2.8%. The mean age was 5.4 ± 4.4 years, the mean lesion size was 6.2 ± 3.4 cm, and the most common indications were hepatoblastoma (28.9%) and hydatid cyst (27.0%). Most underwent cyst surgery (43.0%), followed by minor liver resection (37.7%). Five (2.4%) had conversion to open. The mean operative time was 162.1 ± 99.1 min and mean length of stay was 6.4 ± 4.9 days. Over a mean follow-up of 22.9 ± 24.6 months, one patient died (0.5%). Forty-six children underwent MILS in NCDB (45 laparoscopic, 1 robotic). The mean age was 4.7 ± 5.7 years and mean tumor size was 1.0 ± 1.3 cm. Most underwent wedge/segmental resection (47.8%). Five (10.9%) had conversion to open and mean length of stay was 6.3 ± 5.0 days. CONCLUSION:This first systematic review and NCDB analysis establishes feasibility benchmarks of MILS in children for both benign and malignant liver lesions. MILS is associated with 2-11% conversion rate and mean length of stay of 6 days. LEVEL OF EVIDENCE:Level III evidence.

BACKGROUND:Obesity remains a common barrier to kidney transplantation, with many centers enforcing strict body mass index (BMI) cutoffs due to concerns regarding surgical complexity and postoperative complications. Robotic kidney transplantation (RKT) has emerged as a minimally invasive alternative that may mitigate obesity-associated surgical risks. However, outcomes across granular BMI subgroups, particularly among patients with morbid obesity (BMI ≥40 kg/m2), remain incompletely characterized. METHODS:We performed a retrospective cohort study of adult patients undergoing RKT at a single academic transplant center between November 2021 and September 2025. Patients were stratified by BMI into two primary cohorts (BMI <30 vs ≥30 kg/m2) with a secondary subgroup analysis comparing those with BMI 30-40 vs ≥40 kg/m2. Demographic characteristics, intraoperative metrics, and 30-day postoperative outcomes were compared. RESULTS:A total of 104 patients underwent RKT, with 26 patients with BMI<30 kg/m2, 53 with BMI between 30 and 40 kg/m2, and 25 with BMI ≥40 kg/m2. No significant differences were observed between BMI <30 and ≥30 cohorts in operative time, ischemia times, estimated blood loss, length of stay, delayed graft function, or 30-day readmission. Patients with BMI <30 had a higher rate of 30-day all-cause reoperation (15% vs 3%, p=0.03). In subgroup analysis, patients with BMI ≥40 demonstrated comparable intraoperative parameters and postoperative complication rates to those with BMI 30-40, with no significant differences in graft or patient survival. CONCLUSIONS:Robotic kidney transplantation is associated with comparable perioperative outcomes across BMI categories, including among patients with morbid obesity. These findings challenge rigid BMI-based exclusion criteria and support a more individualized approach to transplant candidacy in the era of robotic surgery.

Kidney transplant benefits those with renal failure and has been shown to be advantageous compared to dialysis. Robotic kidney transplantation is a relatively recent advancement that allows for the procedure to be done with smaller incisions, less blood loss, and potentially superior perioperative outcomes for the patient. In this study, we outline a single-center experience with robotic kidney transplant over 4 years. An analysis of the first 100 robotic kidney transplant performed at a single institution was done. The procedures were done using the Da Vinci Xi robotic interface. Patient records were analyzed through the local electronic medical record. Of 100 total cases, the majority of recipients were male, White, and met BMI criteria for obesity. Most grafts had standard anatomy (one artery, vein, and ureter), with exactly 50

Background: Obesity remains a common barrier to kidney transplantation, with many centers enforcing strict body mass index (BMI) cutoffs due to concerns regarding surgical complexity and postoperative complications. Robotic kidney transplantation (RKT) has emerged as a minimally invasive alternative that may mitigate obesity-associated surgical risks. However, outcomes across granular BMI subgroups, particularly among patients with morbid obesity (BMI ≥40 kg/m 2 ), remain incompletely characterized. Methods: We performed a retrospective cohort study of adult patients undergoing RKT at a single academic transplant center between November 2021 and September 2025. Patients were stratified by BMI into two primary cohorts (BMI <30 vs ≥30 kg/m 2 ) with a secondary subgroup analysis comparing those with BMI 30-40 vs ≥40 kg/m 2 . Demographic characteristics, intraoperative metrics, and 30-day postoperative outcomes were compared. Results: A total of 104 patients underwent RKT, with 26 patients with BMI<30 kg/m 2 , 53 with BMI between 30 and 40 kg/m 2 , and 25 with BMI ≥40 kg/m 2 . No significant differences were observed between BMI <30 and ≥30 cohorts in operative time, ischemia times, estimated blood loss, length of stay, delayed graft function, or 30-day readmission. Patients with BMI <30 had a higher rate of 30-day all-cause reoperation (15% vs 3%, p=0.03). In subgroup analysis, patients with BMI ≥40 demonstrated comparable intraoperative parameters and postoperative complication rates to those with BMI 30-40, with no significant differences in graft or patient survival. Conclusions: Robotic kidney transplantation is associated with comparable perioperative outcomes across BMI categories, including among patients with morbid obesity. These findings challenge rigid BMI-based exclusion criteria and support a more individualized approach to transplant candidacy in the era of robotic surgery.

Donation after circulatory death (DCD) livers increasingly use machine perfusion (MP). This study evaluates MP's impact on older DCD livers based on data from the United Network for Data Sharing, covering all first adult DCD liver transplants (2016-2025). The cohort, divided into pre-MP and MP eras (separated by the FDA approval of the first normothermic MP platform in 2021), showed accelerated growth in DCD liver transplants during the MP era. Donors ≥60 rose 7.8-fold, including donors ≥70 (a USA first). By 2025, DCD livers accounted for 43.2%, with 61.35% from donors ≥50. Normothermic regional perfusion (NRP) (3.0%-16.5%), NMP (2.1%-38.9%), and sequential NRP-NMP (0.1%-10.7%) increased significantly (p < 0.001). The MP era was associated with a decrease in median waitlist time from 112 to 62 days (p < 0.001). Early graft survival was similar across ages. For ages 50-59, 1- and 3-year survivals were 87.9%/78.4% pre-MP and 90.1%/78.8% in the MP era. For 60-69, survival was 85.0%/80.6% pre-MP and 90.0%/71.3% in the MP era. DCD LTs for ≥70 were limited to the MP era with 87.8% 1-year survival. Multivariable Cox regression showed that static cold storage (HR = 1.29), donor age 50-69 versus 18-49, and recipient age (HR = 1.01) increased the risk of graft loss after adjustment. MP is associated with an increased number of older DCD liver transplants and acceptable early graft survival.

INTRODUCTION:Primary sclerosing cholangitis is an immune-mediated cholestatic liver disease characterized by inflammation of the intra- and/or extrahepatic bile ducts and is associated with inflammatory bowel disease. METHODS:We retrospectively compared children (<18 years) and young adults (18-25 years) undergoing first liver transplantation for primary sclerosing cholangitis using United Network for Organ Sharing data (February 2002-December 2024). RESULTS:A total of 531 patients with primary sclerosing cholangitis underwent liver transplantation (160 children; 371 young adults). Children had lower laboratory Model for End-stage Liver Disease / Pediatric End-stage Liver Disease score than young adults (median 13.0 vs 20.0, P < .001). A smaller proportion of children had inflammatory bowel disease (58.8% vs 67.9%, P = .04), ascites (35.9% vs 47.8%, P = .01), and underwent living donor liver transplantation (18.1% vs 29.9%, P < .001) than young adults. Multivariable Cox regression showed decreased risk of patient mortality in children versus young adults (hazard ratio 0.49, 95% confidence interval 0.27-0.89, P = .02) and White, non-Hispanic patients compared with other race/ethnicity (0.44, 0.27-0.73, P = .001), when adjusting for inflammatory bowel disease, Model for End-stage Liver Disease / Pediatric End-stage Liver Disease score, intensive care unit status, graft type, and era. Multivariable Cox regression showed decreased risk of graft loss in female versus male sex (hazard ratio 0.68, 95% confidence interval 0.49-0.96, P = .03) and White, non-Hispanic patients compared with other race/ethnicity (0.71, 0.50-0.99, P = .04), when adjusting for inflammatory bowel disease, Model for End-stage Liver Disease / Pediatric End-stage Liver Disease score, intensive care unit status, graft type, and era. CONCLUSION:Pediatric liver transplantation recipients with primary sclerosing cholangitis exhibit superior patient survival versus young adult liver transplantation recipients, whereas graft survival does not differ significantly. White, non-Hispanic race/ethnicity was independently associated with improved survival, underscoring persistent disparities in liver transplantation outcomes.

OBJECTIVE:To compare isolated liver transplantation (LT) for cystic fibrosis (CF) versus other indications and versus combined liver-lung transplantation (CLLT) for CF in children and identify factors associated with survival. METHODS:We compared clinical and survival data after first isolated LT for CF versus other indications and versus CLLT for CF in children (<18 years) using United Network for Organ Sharing data (02/2002-12/2024). RESULTS:A total of 157 pediatric CF transplant recipients were included (LT: 145; CLLT: 12). Isolated CF LT recipients had higher total bilirubin (TB) than CLLT (median 1.6 vs. 0.7 mg/dL, p = 0.02). A higher proportion of CF transplant recipients with high TB levels (≥1.5 mg/dL) had ascites, encephalopathy, and required life support compared to those with low TB levels (<1.5 mg/dL). CF LT demonstrated superior patient survival versus CF CLLT (log-rank test, p = 0.02; 5-year: 89.1% vs. 72.2%), but inferior versus non-CF LT (log-rank test, p < 0.001; 5-year: 91.5%). Multivariable Cox regression showed increased risk of patient mortality and liver graft loss in CF CLLT recipients compared to isolated CF LT recipients (hazard ratio [HR] = 2.92, 95% confidence interval [95% CI]: 1.20-7.07, p = 0.02 and HR = 2.56, 95% CI: 1.09-5.98, p = 0.03, respectively) and recipients with higher TB levels (HR = 1.05, 95% CI: 1.01-1.10, p = 0.008 and HR = 1.05, 95% CI: 1.01-1.09, p = 0.008, respectively), when adjusting for recipient age, albumin and international normalized ratio (INR) at time of LT, ICU status, and liver graft type. Multivariable Cox regression of isolated LT recipients showed increased risk of patient mortality (HR = 2.03, 95% CI: 1.41-2.93, p < 0.001) and liver graft loss (HR = 1.54, 95% CI: 1.13-2.11, p = 0.006) for CF compared to non-CF etiologies, when adjusting for recipient age, albumin, INR, and TB at time of LT, ICU status, and liver graft type. CONCLUSION:Isolated LT for CF was associated with superior survival compared to CLLT for CF, but inferior survival compared to LT for non-CF indications. Higher TB in CF may be a marker of inferior outcomes post-LT.

Robotic kidney transplantation (RKT) has demonstrated favorable outcomes in living donor cases. However, evidence on its application using deceased donor grafts (dRKT) remains limited. We conducted a retrospective single-center analysis of RKT procedures performed at the University of Colorado Hospital between November 2021 and January 2026. Perioperative, postoperative, and functional outcomes were analyzed, with a sub-analysis comparing normothermic regional perfusion (NRP) and rapid recovery (RR) DCD techniques. A total of 69 dRKTs were performed, with 29 (42.0

Living donor (LD) liver transplant (LT) is associated with improved outcomes compared with deceased donor (DD) LT, including shorter waitlist times, decreased pre-LT mortality, and improved post-LT survival. However, the cost difference between LDLT and DDLT remains unknown. In this study, we used the linked Pediatric Health Information System and Scientific Registry of Transplant Recipients data sets to compare pre-LT, LT, and 1-year post-LT hospitalization costs and resource utilization between children with biliary atresia aged <2 years who received LDLT or DDLT between January 1, 2010, and December 31, 2020. For all children (N = 819), the median cost for transplant hospitalization was less for LDLT ($179 965; interquartile range [IQR]: $130 238-$275 951) than for DDLT recipients ($224 851; IQR: $163 724-$336 550, P < .001), and fewer LDLT (4%) than DDLT recipients (10%, P = .01) required dialysis during transplant hospitalization. In a subanalysis of recipients of a technical variant graft (TVG) (n = 471), transplant hospitalization costs were lower for LDLT ($179 965; IQR: $130 238-$275 951) than for deceased TVG ($249 371; IQR: $171 678-$363 664, P < .001), and fewer LDLT than deceased TVG recipients required dialysis (4% vs 9%, P = .045) and total parenteral nutrition (63% vs 74%, P = .007). In conclusion, LDLT offers an opportunity to decrease costs and should be considered for children in need of LT.

BACKGROUND:Waiting list outcomes for children relisted as status 1/1A following pediatric liver transplantation are not well described in the modern era. The aim of this study was to describe waiting list survival to retransplantation or graft recovery in this population and identify factors associated with these outcomes. METHODS:The United Network for Organ Sharing liver database was retrospectively reviewed for all children re-listed as status 1/1A between March 1, 2002 and June 30, 2022. Logistic regression was performed for the outcomes of waiting list dropout and recovery. RESULTS:679 candidates were relisted as status 1/1A. Ninety-nine (15%) candidates had waiting list dropout, 389 (57%) were retransplanted, and 191 (28%) recovered without retransplant. There was no significant difference in survival across the status 1 versus status 1A eras. In multivariable analysis, portal vein thrombosis, higher Model for End-stage Liver Disease/Pediatric End-Stage Liver Disease score and creatinine at relisting, and mechanical ventilation at original transplant were associated with increased odds for dropout, while non-Hispanic White race/ethnicity was protective against dropout. Mechanical ventilation and portal vein thrombosis at relisting were associated with lower odds of recovery. CONCLUSIONS:Our findings highlight the need for further research and policy changes to improve waiting list survival for this patient population. Portal vein thrombosis is associated with both dropout and decreased odds of recovery and should prompt aggressive pursuit of retransplantation in recipients relisted as status 1A.

INTRODUCTION:Machine perfusion (MP) can help expand the donor pool, yet its use in pediatric liver transplantation (LT) has been limited. We aimed to compare the characteristics and outcomes of children undergoing LT with vs. without MP. METHODS:We retrospectively compared children (< 18 years) undergoing first LT with vs. without MP using United Network for Organ Sharing data (01/01/2016-12/31/2024). The MP group was compared to all non-MP and to propensity score matched non-MP LT recipients. RESULTS:Forty MP LT recipients were compared to 3857 all non-MP and 40 matched non-MP recipients. Compared to all non-MP recipients, MP recipients had a higher laboratory MELD/PELD score (median 16.5 vs. 12.0, p = 0.03) and were more likely to receive split grafts (42.5% vs. 21.6%, p = 0.001) allocated at a national level (65.0% vs. 40.8%, p = 0.007) from older donors (median 16.0 vs. 11.0 years, p < 0.001) with longer organ preservation times (median 15.0 vs. 6.5 h, p < 0.001). Although not statistically different, DCD liver grafts were used in 20.0% of MP LTs compared to 11.1% of all non-MP LTs (p = 0.08). Compared to matched non-MP recipients, MP recipients were more likely to have ascites (47.2% vs. 19.4%, p = 0.02). There was no significant difference regarding patient or graft survival between the MP and all non-MP (p = 0.68 and p = 0.80) or the matched non-MP groups (p = 0.28 and p = 0.14). CONCLUSION:MP can support LT in sick pediatric recipients using split grafts, while allowing for prolonged preservation times and national-level allocation at a larger radius, without impacting survival.

ABSTRACTIntroductionBiliary atresia (BA) is the most common indication for liver transplantation (LT) in children. We aimed to identify risk factors associated with survival in young patients with BA in the modern era.MethodsWe performed a retrospective analysis of BA patients aged < 2 years who received their first isolated LT with available data from the United Network for Organ Sharing database (01/2013–12/2022). Factors included in the multivariable Cox regression were graft type, race/ethnicity, insurance status, laboratory pediatric end‐stage liver disease (PELD) score, history of portal vein thrombosis, and intensive care unit (ICU) status.Results1226 BA LT recipients aged < 2 years were included, of whom 501 (40.9%) received deceased donor whole grafts (DDWG), 425 (34.7%) received deceased donor technical variants (DDTV), and 300 (24.5%) received living donor LT (LDLT). LDLT recipients were more likely to be white (p = 0.008) and have private insurance (p < 0.001). Multivariable analysis demonstrated that ICU status (hazard ratio [HR] = 3.23, 95% confidence interval [95% CI]: 1.72–6.08, p < 0.001) and DDTV graft vs. LDLT (HR = 3.03, 95% CI: 1.14–8.04, p = 0.03) were associated with an increased risk of patient mortality. Factors associated with an increased risk of graft loss included ICU status (HR = 1.89, 95% CI: 1.19–3.00, p = 0.007) and both DDWG (HR = 3.37, 95% CI: 1.65–6.87, p = 0.001) and DDTV (HR = 3.47, 95% CI: 1.69–7.14, p = 0.001) grafts vs. LDLT.ConclusionLDLT is associated with improved survival in patients with BA aged < 2 years; however, socioeconomic differences exist between LDLT and non‐LDLT recipients. Efforts to promote early equitable referral to centers offering LDLT are essential for improving outcomes in young children with BA.