Liver transplant (LTx) recipients are at increased risk of surgical site infections (SSIs). We explored potential risk factors for SSIs post-LTx including colonisation with multidrug-resistant organisms (MDRO) and aimed to assess the impact of perioperative antibiotics targeted at colonising MDRO on the subsequent risk of SSI. A retrospective analysis of adults undergoing LTx at a tertiary referral centre between 2015–2022 was conducted. MDRO colonisation status was determined by routine rectal screening for MDRO including vancomycin-resistant enterococci and extended-spectrum beta-lactamase-producing (ESBL) and carbapenemase-producing Enterobacterales (CPE) at time of LTx. The primary outcome was SSI defined using CDC/NHSN criteria. Clinical features related to the patient and donor organ were retrieved from medical records. A multivariable analysis was conducted to evaluate the impact of MDRO colonisation and targeted antibiotics on 30-day SSI risk. Of 462 patients who underwent LTx, 157/462 (34.0%) were colonised with MDRO (131 [28.4%] VRE and 38 [8.4%] ESBL/AmpC/CPE). The 30-day SSI rate was 11.9% (55/462), including 16.4% superficial, 5.2% deep incisional and 78.4% organ-space infections. Post-operative biliary complications (aOR 2.1 95% CI 0.98-4.27; P=0.048) and post-LTx haemodialysis (aOR 3.84; 95% CI 1.75-8.17, P= 6e-04) were significantly associated with increased SSI risk on multivariable analysis. There was no association between MDRO colonisation and risk of SSI following LTx (aOR 1.47; 95% CI 0.79-2.71, P=0.2195)). Among MDRO colonised patients (n=157), the use of perioperative antibiotics targeted at colonising MDRO was not associated with reduced SSI risk (aOR 0.40; 95% CI 0.08-1.4; P=0.189). SSIs following LTx most commonly involve deep organ spaces. MDRO colonisation was not independently associated with an increased SSI risk, and receiving directed-perioperative antibiotic prophylaxis did not decrease SSI risk. All Authors: No reported disclosures

BACKGROUND:Intestinal transplant is a rare procedure reserved for patients with intestinal failure who cannot be sustained on total parenteral nutrition due to severe, life-threatening complications. This study aims to describe the activity and outcomes of intestinal transplantation undertaken in Australia. METHODS:Observational retrospective cohort study of all adult and paediatric patients who have received an intestinal transplant in Australia. The primary outcomes were patient and graft survival, with secondary outcomes including incidence of post-transplant enteral autonomy and post-transplant complications. RESULTS:Nineteen patients (14 adults, five children) received a total of 20 intestinal transplants in Australia between 2010 and 2026. One-year conditional graft and patient survival was 87% and 93% respectively, with 5-year conditional graft and patient survival rates of 67% and 75% respectively. The median time to cease total parenteral nutrition and achieve enteral autonomy after transplant was 21 days (interquartile range: 17-30 days). Median body mass index was within ideal range for adult patients by 12 months post-transplant and growth centiles improved for paediatric patients. Eight patients (40%) experienced a total of 14 episodes of rejection at a median onset of 7.5 months after transplant, of which five were graded severe. Rates of post-transplant lymphoproliferative disorder and graft-versus-host disease were low (5% each). CONCLUSIONS:The Australian Intestinal Transplant Service demonstrates excellent patient outcomes, with short- to medium-term graft and patient survival similar to that of leading international centres and enteral autonomy achieved in all patients. Intestinal transplant is now an acceptable, life-saving procedure in appropriately selected patients in our region.

BACKGROUND:The 2025 University of Melbourne Department of Surgery Research Showcase, held on 18 November 2025, brought together surgeons, researchers, educators, and trainees from across seven clinical precincts to examine emerging directions in surgical education research. The event aimed to facilitate knowledge exchange, interdisciplinary collaboration, and critical reflection on evolving training paradigms. METHODS:The Showcase was delivered in a hybrid format, combining in-person and virtual participation to maximize accessibility and engagement. The program comprised keynote presentations and precinct-led talks, alongside thematic discussions addressing contemporary issues in surgical education. Contributions were drawn from multiple disciplines, including engineering, data science, ophthalmology, oncology, and general surgery. RESULTS:Presentations highlighted innovations in simulation-based learning, robotic and technology-enhanced training, Artificial Intelligence-enabled assessment, large-scale online education, and real-time intraoperative performance monitoring. Additional themes included curriculum reform, competency-based assessment, trainee underperformance, gender equity in surgical training, and the transition from trainee to consultant. The Showcase demonstrated the increasing prominence of educational scholarship within surgical disciplines and illustrated how multidisciplinary approaches can strengthen training frameworks and support workforce sustainability. CONCLUSION:The Research Showcase provides a model for fostering regional academic communities in surgery through accessible, collaborative platforms. Its findings offer valuable insights for educators, academic surgeons, and policymakers addressing current challenges in surgical training. The reflections arising from the event contribute to the broader discourse in surgical education research and have important implications for the design of future curricula, assessment strategies, and professional development pathways.

This ‘How I Do It’ study provides a step‐by‐step video demonstration and discussion of relevant anatomical and pathophysiological considerations to safely replicate our novel two‐stage technique for nephrectomy and caval thrombectomy for level IV renal cell carcinoma complicated by Budd–Chiari syndrome.

Patients awaiting liver transplant (LT) are commonly prescribed anticoagulation. Indications include portal vein thrombosis and atrial fibrillation. The safety of continuing apixaban until the time of deceased donor LT is unknown. We assessed the safety of apixaban, administered within 48 hours of LT. A total of 26 patients were treated with apixaban within 48 hours of LT surgery. The median Modelfor End-stage Liver Disease (MELD) score was 18.5 (interquartile range, 16.2-20.0). Using 2:1 propensity-score matching, 52 control patients were identified from a prospectively maintained registry. The coprimary outcome was packed red blood cells and intraoperative cell salvage volume transfused during LT. The median time between the last apixaban dose and surgery start was 18.2 hours. There was no significantly increased intraoperative blood product requirement in patients on apixaban. Packed red blood cells (898 vs 997 mL, P = 1.00) and intraoperative cell salvage volumes (1500 vs 1144 mL, P = .87) were comparable between patients treated with apixaban and controls. Fresh frozen plasma (133 vs 306 mL, P = .16), cryoprecipitate (60 vs 136 mL, P = .11), and platelet volumes (105 vs 302 mL, P = .06) were also comparable. There was no difference in return to theater for early bleeding or in graft or patient survival at 12 months posttransplant. Apixaban appears safe to continue in the peri-LT setting for patients awaiting deceased donor LT in this population with low MELD scores.

BackgroundThe concept of a “textbook outcome” is emerging as a metric for ideal surgical outcomes. We aimed to evaluate the impact of an advanced haemodynamic monitoring (AHDM) algorithm on achieving a textbook outcome in patients undergoing hepatobiliary–pancreatic surgery.MethodsThis retrospective, multicentre observational study was conducted across private and public teaching sectors in Victoria, Australia. We studied patients managed by a patient-specific, surgery-specific haemodynamic algorithm or via usual care. The primary outcome was the effect of using a patient-specific, surgery-specific AHDM algorithm for achieving a textbook outcome, with adjustment using propensity score matching. The textbook outcome criteria were defined according to the International Expert Delphi Consensus on Defining Textbook Outcome in Liver Surgery and Nationwide Analysis of a Novel Quality Measure in Pancreatic Surgery.ResultsOf the 780 weighted cases, 477 (61.2%, 95% CI: 57.7%–64.6%) achieved the textbook outcome. Patients in the AHDM group had a higher rate of textbook outcomes [n = 259 (67.8%)] than those in the Usual care group [n = 218 (54.8%); p < 0.001, estimated odds ratio (95% CI) 1.74 (1.30–2.33)]. The AHDM group had a lower rate of surgery-specific complications, severe complications, and a shorter hospital length of stay (LOS) [OR 2.34 (95% CI: 1.30–4.21), 1.79 (95% CI: 1.12–2.85), and 1.83 (95% CI: 1.35–2.46), respectively]. There was no significant difference between the groups for hospital readmission and mortality.ConclusionsAHDM use was associated with improved outcomes, supporting its integration in hepatobiliary–pancreatic surgery. Prospective trials are warranted to further evaluate the impact of this AHDM algorithm on achieving a textbook impact on long-term outcomes.

The liver has a strong regenerative capacity that ensures patient recovery after hepatectomy and liver transplantation. The portal system plays a crucial role in the dual blood supply to the liver, making it a significant factor in hepatic function. Several surgical strategies, such as portal vein ligation, associating liver partition and portal vein ligation for staged hepatectomy, and dual vein embolization, have highlighted the portal system’s importance in liver regeneration. Following hepatectomy or liver transplantation, the hemodynamic properties of the portal system change dramatically, triggering regeneration via shear stress and the induction of hypoxia. However, excessive portal hyperperfusion can harm the liver and negatively affect patient outcomes. Furthermore, as the importance of the gut–liver axis has gradually been revealed, the effect of metabolites and cytokines from gut microbes carried by portal blood on liver regeneration has been acknowledged. From these perspectives, this review outlines the molecular mechanisms of the portal system’s role in liver regeneration and summarizes therapeutic strategies based on the portal system intervention to promote liver regeneration.

BACKGROUND:Normothermic machine perfusion (NMP) aims to reduce ischemia-reperfusion injury in donor livers and its clinical manifestation, early allograft dysfunction (EAD) by maintaining perfusion and oxygenation. However, there is limited data on which NMP perfusate biomarkers might be associated with such EAD and the role of perfusate hemoglobin has not been assessed. METHODS:We performed a pilot retrospective analysis of adult donor livers undergoing NMP between 2020 and 2022 at our center. NMP was commenced at the recipient hospital after initial static cold storage. All NMP circuits were primed in the same manner according to the manufacturer's instructions. Livers were stratified by initial perfusate hemoglobin below (≤5.2 mmol/L) or above (>5.2 mmol/L) the median. The association between hemoglobin levels and EAD or recipient peak transaminase levels was assessed. RESULTS:Among 23 livers, eight were considered unsuitable for transplantation, leaving 15 livers for assessment. Higher initial hemoglobin was associated with a lower risk of EAD (0% vs. 55.6%, p = 0.04). Perfusate hemoglobin decreased after NMP initiation (p = 0.003) and negatively correlated with recipient peak transaminase levels (ALT: ρ = -0.72, p = 0.002; AST: ρ = -0.79, p < 0.001). Consistently, higher hemoglobin livers also demonstrated lower perfusate liver enzymes. CONCLUSIONS:Perfusate hemoglobin levels decreased during NMP, and lower perfusate hemoglobin levels were associated with a higher incidence of EAD and higher levels of liver injury markers. Maintaining higher hemoglobin levels during NMP may help reduce ischemia-reperfusion injury and prevent or attenuate EAD. Larger prospective studies are needed to validate the findings of this pilot study.

BACKGROUND:Very little information is currently available on the use and outcomes of venovenous bypass (VVB) in liver transplantation (LT) in adults in Australia. In this study, we explored the indications, intraoperative course, and postoperative outcomes of patients who underwent VVB in a high-volume LT unit.METHODS:The study was a single-center, retrospective observational case series of adult patients who underwent VVB during LT at Austin Health in Melbourne, Australia between March 2008 and March 2022. Information on baseline preoperative status and intraoperative variables, including specific VVB characteristics as well as postoperative and VVB-related complications was collected. The lengths of intensive care unit and hospital stays as well as intraoperative and in-hospital mortality were recorded.RESULTS:Of the 900 LTs performed at this center during the aforementioned 14-year period, 27 (3%) included a VVB procedure. VVB was performed electively in 16 of these 27 patients (59.3%) and as a rescue technique to control massive bleeding in the other 11 (40.1%). The median (interquartile range [IQR]) age of those who underwent VVB procedures was 48 (39-55) years; the median age was 56 (47-62) years in the non-VVB group (p<0.0001). The median model for end-stage liver disease (MELD) scores were similar between the two patient groups. Complete blood data was available for 622 non-VVB patients. Twenty-six VVB (96.3%) and 603 non-VVB (96.9%) patients required intraoperative blood transfusions. The median (IQR) number of units of packed red blood cells transfused was 7 (4.8-12.5) units in the VVB group compared to 3.0 units (1.0-6.0) in the non-VVB group (p<0.0001). Inpatient mortality was 18.5% and 1.1% for the VVB and non-VVB groups, respectively (p<0.0001). There were no significant differences in length of hospital stay or incidence of acute kidney injury, primary graft dysfunction, or long-term graft failure between the two groups. Patients in the VVB group experienced a higher rate of postoperative non-anastomotic biliary stricture compared to patients in the non-VVB group (33% and 7.9%, respectively; p = 0.0003).CONCLUSIONS:VVB continues to play a vital role in LT. This case series highlights the heightened risk of major complications linked to VVB. However, the global transition to selective use of VVB underscores the urgent need for collaborative multi-center studies designed to address outstanding questions and parameters related to the safe implementation of this procedure.

The presence of precursor to exhausted (T-pex) CD8(+) T cells is important to maintain robust immunity following treatment with immune checkpoint inhibition (ICI). Impressive responses to ICI are emerging in patients with stage II-III mismatch repair (MMR)-deficient (dMMR) colorectal cancer (CRC). We found 64% of dMMR and 15% of mismatch repair-proficient (pMMR) stage III CRCs had a high frequency of tumor infiltrating lymphocytes (TIL-hi). Furthermore, expression of TCF-1 (Tcf7) by CD8(+) T cells predicted improved patient prognosis and T(pex )cells (CD3(+)CD8(+)TCF-1(+)PD-1(+)) were abundant within lymphoid aggregates of stage III CRCs. In contrast, CD3(+)CD8(+)TCF-1(-)PD-1(+ )cells were more abundant at the invasive front and tumor core, while gamma delta T cells were equally abundant in all tumor areas. Interestingly, no differences in the frequency of T-pex cells were observed between TIL-hi dMMR and TIL-hi pMMR CRCs. Therefore, T-pex cell function and ICI response rates in TIL-hi CRC warrants further investigation.

BACKGROUND:Ex vivo normothermic machine perfusion (NMP) is an organ preservation technique that enables an extended assessment of graft suitability before liver transplantation (LT). Established monitoring protocols used during NMP vary significantly in their assessment of transplant suitability when applied to the same grafts. Graft-derived cell-free DNA (gdcfDNA) analysis is an emerging tool for monitoring graft health post-transplantation. We investigated the feasibility of monitoring gdcfDNA during NMP for LT in a proof-of-concept, observational study. METHODS:Serial plasma and bile samples were collected during NMP for 10 consecutive grafts, at 15 min post-machine reperfusion and then 2-h intervals. Digital polymerase chain reaction was used to quantify gdcfDNA at each time point. RESULTS:Five grafts were suitable for LT, there were no cases of primary nonfunction or death in the recipients. gdcfDNA was quantified in all bile and plasma samples (n > 100). In plasma, gdcfDNA concentrations climbed post-machine reperfusion until 4.25 h (median 2.25 h = 15.98 × 10 6 copies/mL, 4.25 h = 40.21 × 10 6 copies/mL). gdcfDNA levels then diverged significantly when comparing the viable and non-viable graft groups (6.25 h, median viable: 117.15 × 10 6 copies/mL versus non-viable: 16.72 × 10 6 copies/mL, P  = 0.01). These opposing trends correlated in each graft and in all cases with the viable/non-viable outcome. There was a trend of gradual decline in bile gdcfDNA from viable grafts post-machine reperfusion; discarded grafts showed more variable patterns of release. CONCLUSIONS:gdcfDNA analysis during NMP is a feasible and potential tool to inform viability assessment during NMP for LT. Bile gdcfDNA monitoring offers the prospect of an objective means to assess the degree of biliary injury associated with organ procurement.

BackgroundBiliary reconstruction technique during liver transplant (LT) for primary sclerosing cholangitis (PSC) remains controversial. This study aimed to evaluate the incidence of biliary complications in patients with PSC having a duct-to-duct (DD) anastomosis or Roux-en-Y hepaticojejunostomy (HJ).MethodsA retrospective medical record review of patients with PSC undergoing LT at a single center between June 1st, 2000 and December 31st, 2022 was performed. Primary and secondary endpoints were the incidence of biliary strictures (anastomotic [BAS] and non-anastomotic strictures [NAS]) and non-stricture complications, respectively. Univariable and multivariable regression analyses were performed to identify associations with BAS formation. Patient survival was assessed using a Kaplan-Meier curve.ResultsFrom 105 transplants performed for 101 patients, 54 (51.4%) and 51 (48.5%) received DD and HJ anastomoses. Mean recipient age and follow-up was 47 +/- 13 years and 98 +/- 69 months. BAS was more common (48.1% vs. 27.5%, OR 2.45, 95% CI 1.09-5.54, p = 0.03) and occurred earlier (4.8 months, IQR 2.3-13.1 vs. 41.8 months, IQR 7.2-88.7, p = 0.001) in the DD than the HJ group. NAS (seen in 36.2% of transplants) had a comparable incidence (p = 0.53) in HJ (38.9%) and DD (33.3%) groups. No difference was seen between cohorts regarding time to NAS, requirement for extended biliary dilatation programs (clinically significant biliary stricture), bile leak, and graft failure. On multivariable analysis, only the anastomotic technique was associated with BAS (DD adjusted OR 3.00, 95% CI 1.19-7.56, p = 0.02).ConclusionIn carefully selected patients with PSC, DD anastomosis yielded similar outcomes to HJ anastomosis after liver transplantation.

Introduction Biliary complications remain a common cause of morbidity after liver transplantation and often require invasive interventions to manage. We aimed to assess the technical feasibility and safety of placement of a biodegradable stent across the biliary anastomosis at the time of liver transplantation in patients having a duct to duct biliary reconstruction. Methods For this prospective, single-arm, descriptive study, 10 consecutive patients undergoing whole graft, deceased donor, liver transplantation and duct-to-duct biliary tract reconstruction were enrolled and a biodegradable biliary stent was sutured into the bile duct across the anastomosis. Results In all 10 patients it was technically feasible to place and secure the stent safely during the operation. After >6 months (median of 212 days) follow up, no patients had developed biliary anastomotic stricture. One patient had transient bile leak immediately post-operative that was managed conservatively. One patient required endoscopic intervention for non-anastomotic stricture development and biliary cast material that had resulted in stent dysfunction. Discussion The results of this study suggest surgical feasibility of placement of an absorbable biliary stent across the biliary anastomosis at the time of liver transplantation, as well as an acceptable safety profile. Further studies are required to confirm these safety and feasibility findings and to assess efficacy in reducing rates of biliary complications and the need for endoscopic intervention in the early post-transplant period.