Abstract Background Management of pancreaticobiliary malignancy is complex and multi-disciplinary. Decompression of malignant biliary obstruction (MBO) is preferentially achieved with endoscopic retrograde cholangiopancreatography (ERCP) and biliary stent placement. This may improve the quality of life for patients with unresectable disease and improve outcomes in resectable/borderline-resectable disease. Purpose To assess quality outcomes in patients undergoing biliary stenting for MBO. Method This is a retrospective chart audit of patients referred to the University of Alberta Hospital (UAH) for suspected or confirmed MBO. The primary outcome was clinical success (reduction in bilirubin of >50% at 30 days). Secondary outcomes were technical success, type of stent used, need for re-intervention, adverse events (AEs), time from stent placement to surgery or cancer centre assessment, and survival. Result(s) Between January 2020 and June 2022, 222 patients (102 female, 46%) with a mean age of 70±1 years (range 34-93 years) underwent 290 ERCPs. The cause of MBO was pancreatic cancer in 130 (59%), cholangiocarcinoma in 32 (14%), ampullary cancer in 9 (4%), and others in 51 (23%). Technical success for stent insertion on first ERCP was achieved in 180/222 patients (81%) with only brushings performed in 2. Of the 40 patients (18%) with unsuccessful ERCP, further success was achieved by repeat ERCP (8), percutaneous transhepatic drainage (PTC, 15), PTC with rendezvous ERCP (1), surgical decompression (3), and endoscopic ultrasound-guided biliary drainage (1). No biliary drainage was performed in 12 patients. Overall, ERCP with stent insertion was technically successful in 188/222 patients (85%). A total of 233 biliary stents were inserted (38 plastic, 195 metal). Clinical success was achieved in 20/38 patients (53%) with plastic stents and 151/181 patients (83%) with metal stents (Χ2 17.4 p<0.05). Adverse events were encountered in 33 patients (11%) with stent migration occurring in 8 (3%), cholangitis in 7 (2%), post-ERCP pancreatitis in 7 (2%), post-sphincterotomy bleeding in 4 (1%), and death in 2 (1%). Re-intervention was required in 36 patients (20%) after initial ERCP with successful stent placement. The re-intervention rate was significantly higher with plastic stents (14/27, 52%) than with metal stents (22/153, 14%) after initial ERCP (Χ2 20.1 p<0.001). The overall survival was a mean of 249±16 days (5-967) for patients with plastic stents and 248± 16 days (1-959) for those with metal stents. Survival was significantly worse in patients with unresectable disease vs resectable/borderline-resectable disease (Log rank 38.89, p<0.001), Figure 1. Image Conclusion(s) In MBO, metal stents appear to provide significantly better biliary drainage, with less need for re-intervention, but do not appear to be associated with any survival benefit over plastic stents. We hope that this quality assurance project will help in the development of a regional management pathway for optimizing the care of patients presenting with MBO. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Objective: To describe the development of multimodal, web-based educational resources about cirrhosis alongside patients and caregivers. Methods: We used an iterative process that was guided by the Strategy for Patient Oriented Research (SPOR) patient engagement framework in describing patient engagement activities to partner with a team of 16 patients and caregivers (Patient Advisory Team (PAT)). This process included five phases: a) Prioritize and gather content, b) design and build the website and videos, c) gather and integrate feedback, d) improve user accessibility, and e) assess usability and knowledge uptake for users. Results: This 2-year process resulted in a 55-page website and 78 animated and live-action videos on cirrhosis complications, procedures, nutrition, and exercise. We implemented usability testing through pre-defined tasks and a think-aloud method from individuals with no previous exposure to the website to assess navigation, appearance, and content issues. Following usability testing, we have been gathering quantitative data from each unique page about relevance and ease of use, as well as qualitative data on the value of the content itself. Conclusions: Collaboration between clinicians, patients, and caregivers is key to developing high-quality digital educational resources. Lessons from our process may help other organizations looking to address disease-specific knowledge gaps. Next steps with www.cirrhosiscare.ca will be continued iterative refinement and structured impact evaluation. Innovation: This project used a patient-centered approach to develop a comprehensive online educational resource for patients with cirrhosis. By having patients with cirrhosis as a key part of our team, we ensured that the site met the needs of this unique population.

Introduction: Liver transplantation of foreign nationals (FNLT) who acutely decompensate remains to be an ethical dilemma that many Canadian transplant centres face. We present a case report of a cirrhotic foreign national who acutely decompensated in Alberta, Canada requiring liver transplantation. Case Description/Methods: A 57-year-old woman from Vietnam with chronic Hepatitis B (HBV) infection who was visiting family members in Alberta, Canada was admitted to hospital with liver failure secondary to reactivation of HBV. She was previously on tenofovir but was stopped due to financial reasons. She failed to respond to medical management including anti-viral therapies in-hospital and a decision was made to proceed with liver transplantation. She received a donation after cardiac death (DCD) liver with post-op complications including hepatic artery thrombosis (HAT) managed conservatively with heparin, and post-transplant diabetes managed with diabetic diet. The liver explant showed cirrhosis and severe hepatitis. Patient currently remains on a visitor visa in Canada, with plans for extending her stay and is paying out-of-pocket for all medications due to lack of insurance. Long-term plan includes life-long entecavir for HBV and aspirin for HAT, monthly intramuscular injections of hepatitis B immunoglobulin (HBIG) and mycophenolic acid for the first 12 months post-transplant and a generic form of tacrolimus. Discussion: Literature shows that many transplant programs in Canada will consider patients for transplant based on medical needs despite foreign nationality. The Canadian Liver Transplant Network has a consensus of accepting FNLT based on emergent need. Previously it permitted up to a maximum of 5% of the total available cadaveric livers. There remains challenges including lack of awareness among hepatologists of the existence of such consensus and obtaining financial coverage on a provincial level. This case report will hopefully generate a discussion and raise awareness on guidelines around FNLT in Canada.

BACKGROUND: Widespread administration of COVID-19 vaccinations have led to reports of rare but potentially serious side effects. METHODS: We present two cases of acute hepatitis following mRNA BNT162b2 (Comirnaty, Pfizer-BioNTech) vaccination. RESULTS: A 25-year-old male presented to hospital with progressive jaundice 5 days following his second dose of Comirnaty. Initial bloodwork revealed severe hepatocellular enzyme elevation and conjugated hyperbilirubinemia with preserved INR. Extensive serologic workup was negative, with normal imaging. Percutaneous liver biopsy was performed and revealed acute cholestatic hepatitis possibly related to drug-induced liver injury. He was started on prednisone 40 mg daily with good initial response but had a second flare; a biopsy was repeated which showed near-identical findings. Steroids were discontinued given non-response and the patient had gradual near complete resolution of liver enzymes and hyperbilirubinemia. A 32-year-old male presented with a 4-week history of nausea followed by progressive choluria, jaundice, and pruritis. He received his second dose of Comirnaty vaccination two weeks prior to presentation. Initial bloodwork showed mixed enzyme elevation with hyperbilirubinemia. Serological workup and imaging were unrevealing. He underwent liver biopsy which showed severe intrahepatic cholestasis, with drug-induced liver injury being suggested as most likely cause. His course was self-limited with resolution of serological abnormalities and symptoms. CONCLUSIONS: While overwhelmingly safe on a population level, our case series illustrate two cases of acute icteric hepatitis following mRNA BNT162b2 vaccination. Clinicians should be aware of this association with hepatic inflammation and consider vaccine history an important component of evaluating patients with acute liver injury.

Introduction: Increasing evidence supports liver transplant in selected patients with alcohol related liver disease (ALD) without six months of abstinence. Though there is emerging data on those accepted for transplant, there is little data on patients not accepted through this pathway. Studies on candidate selection can help improve the selection criteria. Methods: Referrals made to on-call hepatologists were documented on paper copies of inclusion criteria checklists. Those meeting criteria were accepted for assessment by a multi-disciplinary team. Patients deemed good candidates were listed for transplant. While on the transplant waitlist, patients underwent random blood alcohol testing as proof of ongoing abstinence. We retrospectively analyzed data from the inclusion criteria checklists. Chart reviews were conducted to determine date of last follow-up and living status. Statistical analysis were carried out to compare characteristics between patients accepted for assessment and those declined at initial referral. These included average age, average MELD-Na and checklist criteria. Results: We reviewed 56 referrals to the Exception Pathway from August 2018 to October 2020. Of these, 3 were excluded due to missing data. From the 53 referrals, 37 (70%) were declined at initial triage and 16 (30%) were accepted for full assessment. Although there was no difference in age or sex, the average MELD-Na was higher for accepted patients (37) than those declined (31). Analysis of individual inclusion criteria showed a significant difference between groups for all criteria except for presence of co-morbid drug use (Table 1). Of the 53 referred, 23 had no evidence of alcoholic hepatitis (AH), 2 were unclear and 14 met criteria. Further criteria were applied to patients with AH. Analysis of these revealed no difference between the groups in regards to non-responsiveness to steroids or previous non-compliance. As compared to those not accepted, accepted patients had no significant difference in survival at last known date of follow-up. Of those accepted for assessment, six were listed for transplant, three were transplanted, two patients died while listed and one improved. Conclusion: Our retrospective study is unique as it characterizes patients not accepted through this pathway. Criteria that showed no difference between groups, raise the question of whether they should be included in the initial assessment. Further data on patients rejected through this pathway is need to help improve selection criteria.Table 1.: Tacrolimus-based immunosuppressive management among liver transplant recipients hospitalized with SARS-CoV-2 infection a Time from positive SARS-CoV-2 PCR nasal swab to tacrolimus trough b AST and ALT values at time of admission Abbreviations: ALT, alanine aminotransferase, aspartate aminotransferase, AST; LT, liver transplant; MMF, mycophenolate mofetil; IS, immunosuppression; Pred, prednisone; Tac, tacrolimus

Chronic kidney disease (CKD) is common following liver transplantation (LT). We aimed to investigate the frequency, risk factors, and impact of CKD on cardiovascular disease (CVD), graft, and patient survival. We analyzed 752 patients who received LT at the University of Alberta. Development of CKD was defined as eGFR <60 ml/min for greater than 3 months, intrinsic renal disease or presence of end‐stage renal disease requiring renal replacement therapy. 240 patients were female (32%), and mean age at LT was 53 ± 11 years. CKD was diagnosed in 448 (60%) patients. On multivariable analysis, age (OR 1.3; P = 0.01), female sex (OR 3.3; P < 0.001), baseline eGFR (OR 0.83; P < 0.001), MELD (OR 1.03; P = 0.01), de novo metabolic syndrome (OR 2.3; P = 0.001), and acute kidney injury (OR 3.5; P < 0.001) were associated with CKD. A higher tacrolimus concentration to dose ratio was protective for CKD (OR 0.69; P < 0.001). CKD was associated with post‐transplant CVD (26% vs. 16% P < 0.001), reduced graft (HR 1.4; P = 0.02), and patient survival (HR 1.3; P = 0.03). CKD is a frequent complication following LT and is associated with an increased risk of CVD and reduced graft and patient survival.

BACKGROUND: Primary sclerosing cholangitis (PSC) is an immune-mediated biliary disorder of unknown etiology with no effective treatment. The purpose of this study was to better prognosticate the development of cirrhosis, decompensation, and requirement for liver transplantation (LT) in PSC patients based on serum immunoglobulin G4 (IgG4) levels. METHODS: A retrospective chart review was conducted on PSC patients seen at the University of Alberta Hospital between 2002 and 2017. PSC patients were categorized as high IgG4 group (≥70 mg/dL) or normal IgG4 group (<70 mg/dL). Laboratory parameters, clinical characteristics, and outcomes were compared between the groups. RESULTS: One hundred and ten patients were followed over a mean period of 7.3 (SD 5) years. Seventy-two patients (66%) were male, the mean age at diagnosis of PSC was 35 (SD 15) years, and inflammatory bowel disease (IBD) was present in 80 patients (73%). High IgG4 levels were found in 37 patients (34%). PSC patients with high IgG4 had a shorter mean cholangitis-free survival time (5.3 versus 10.4 years, p = 0.02), cirrhosis-free survival time (8.7 versus 13.0 years, p = 0.02), and LT-free survival time (9.3 years versus 18.9 years, p <0.001). IgG4 ≥70 mg/dL was independently associated with liver decompensation and LT-free outcomes. A cut-off IgG4 value of ≥70 mg/dL performed better than a cut-off value of ≥140 mg/dL to predict time to LT (area under the curve [AUC] 0.68, p = 0.03, sensitivity 72%, specificity 78%). CONCLUSIONS: Serum IgG4 ≥70 mg/dL in PSC predicts a shorter time to cirrhosis decompensation and LT.

Antibody mediated rejection (AMR) is an area of great importance in solid organ transplantation. Donor-specific antibodies (DSA) have emerged as relevant biomarkers in predicting graft function and survival. DSA detected post-transplant may either be preformed or de novo and emerging evidence suggests de novo DSA, in particular, is associated with inferior graft outcomes. In contrast to the clear role that AMR plays in renal and thoracic organ transplantation, its importance in liver transplants remains controversial. The aim of this study was to determine the risk factors associated with de novo DSA formation and to evaluate its role in determining clinical outcomes after liver transplantation. This single-center retrospective study compiled data on liver transplants performed between 2005 and 2019 in Edmonton, Canada. Data collected from medical charts included gender, age at transplant, reason for transplant, and immunosuppressive regimens, among several others. The presence of DSA was determined by single antigen flow beads until 2009 and by Luminex thereafter. Potential predictors of DSA formation were evaluated using Cox proportional hazard models. Graft survival estimates were obtained using the Kaplan-Meier method and comparisons between patient groups were conducted using the log-rank test. Between 2005–2019, 131 patients had measurements of DSA both before and after liver transplantation. In this cohort, 17 patients (13%) tested negative on DSA screening before transplant but developed new antibodies against either Class I or Class II molecules post-transplant. Risk factor analysis revealed transplants performed in the setting of autoimmune liver disease (PSC, PBC, and autoimmune hepatitis) had higher risks of developing de novo DSA post-transplant (p=0.002. See Table 1). Graft survival probability at 5- and 10-years was 72% and 61% in those with de novo DSA formation, compared to 93% and 89% in patients without de novo DSA formation (p=0.04. See Figure 1). Overall patient survival was similar between the two groups. In this single-center study, a transplant done in the setting of autoimmune liver disease had a higher risk of de novo DSA formation. Furthermore, de novo DSA formation lead to a decreased graft survival time in liver transplant patients but overall patient survival was not significantly decreased. A standard approach to DSA monitoring, especially in high risk populations, is required to better understand its prevalence and impact in liver transplantation. None

Background Progressive familial intrahepatic cholestasis (PFIC) type 3 is an autosomal recessive disorder arising from mutations in the ATP-binding cassette subfamily B member 4 ( ABCB4 ) gene. This gene encodes multidrug resistance protein-3 (MDR3) that acts as a hepatocanalicular floppase that transports phosphatidylcholine from the inner to the outer canalicular membrane. In the absence of phosphatidylcholine, the detergent activity of bile salts is amplified and this leads to cholangiopathy, bile duct loss and biliary cirrhosis. Patients usually present in infancy or childhood and often progress to end-stage liver disease before adulthood. Case presentation We report a 32-year-old female who required cadaveric liver transplantation at the age of 17 for cryptogenic cirrhosis. When the patient developed chronic ductopenia in the allograft 15 years later, we hypothesized that the patient’s original disease was due to a deficiency of a biliary transport protein and the ductopenia could be explained by an autoimmune response to neoantigen that was not previously encountered by the immune system. We therefore performed genetic analyses and immunohistochemistry of the native liver, which led to a diagnosis of PFIC3. However, there was no evidence of humoral immune response to the MDR3 and therefore, we assumed that the ductopenia observed in the allograft was likely due to chronic rejection rather than autoimmune disease in the allograft. Conclusions Teenage patients referred for liver transplantation with cryptogenic liver disease should undergo work up for PFIC3. An accurate diagnosis of PFIC 3 is key for optimal management, therapeutic intervention, and avoidance of complications before the onset of end-stage liver disease.

Hepatocellular carcinoma (HCC) is the second most common lethal cancer, and there is a need for effective therapies. Selective internal radiation therapy (SIRT) has been increasingly used, but is not supported by guidelines due to a lack of solid evidence. Determine the efficacy and safety of SIRT in HCC across the Barcelona Clinic Liver Cancer (BCLC) stages A, B, and C. Consecutive patients that received SIRT between 2006 and 2016 at two centers in Canada were evaluated. We analyzed 132 patients, 12 (9%), 62 (47%), and 58 (44%) belonged to BCLC stages A, B, and C; mean age was 61.2 (SD ± 9.2), and 89% were male. Median survival was 12.4 months (95% CI 9.6–16.6), and it was different across the stages: 59.7 (95% CI NA), 12.8 (95% CI 10.2–17.5), and 9.3 months (95% CI 5.9–11.8) in BCLC A, B, and C, respectively (p = 0.009). Independent factors associated with survival were previous HCC treatment (HR 2.01, 95% CI 1.23–3.27, p = 0.005), bi-lobar disease (HR 2.25, 95% CI 1.30–3.89, p = 0.003), ascites (HR 1.77, 95% CI 0.99–3.13, p = 0.05), neutrophil-to-lymphocyte ratio (HR 1.11, 95% CI 1.02–1.20, p = 0.01), Albumin–Bilirubin (ALBI) grade-3 (HR 2.69, 95% CI 1.22–5.92, p = 0.01), tumor thrombus (HR 2.95, 95% CI 1.65–5.24, p < 0.001), and disease control rate (HR 0.62, 95% CI 0.39–0.96, p = 0.03). Forty-four (33%) patients developed severe adverse events, and ALBI-3 was associated with higher risk of these events. SIRT has the potential to be used across the BCLC stages in cases with preserved liver function. When using it as a rescue treatment, one should consider variables reflecting liver function, HCC extension, and systemic inflammation, which are associated with mortality.

Background. The introduction of direct-acting antivirals (DAA) for HCV has led to high rates of HCV eradication. Treatment of patients awaiting liver transplantation (LT) has been controversial. Recent data suggests that DAA treatment may accelerate recurrent HCC. The impact of DAA on delisting for HCC progression or recurrent HCC post-LT has not been well characterized. Methods. A retrospective review of both waitlist patients and LT recipients at a single institution was performed. Patient demographics, HCV treatment, HCC features and treatments, biopsy results, and graft and patient survival were evaluated. Patients on the LT waitlist or who were transplanted between January 2014 and December 2015 were included. Data was collected through December 2017 to have a minimum of two years of follow-up. Results. In the study period, 128 adult LT were performed. 44 patients were HCV+, and 68.2% (N=30) also had HCC. 38.6% (N=17) of HCV+ patients received DAA pre-LT, and 94.1% (N=16/17) achieved sustained virologic response (SVR) pre-LT. Among untreated HCV+ patients who underwent LT, 81.5% (N=22/27) received DAA post-LT, with 82.6% achieving SVR post-LT (N=18/22). 82.1% (N=23/28) of untreated post-LT patients underwent liver biopsy prior to therapy, and 52.2% had at least F1 METAVIR fibrosis. 87.5% (N=14/16) of active waitlist patients received DAA and achieved SVR. HCV eradication did not result in higher rates of delisting for HCC progression. Due to local HCC listing criteria of total tumor volume and AFP, 60% (N=18/30) of HCV+/HCC patients were beyond Milan criteria at the time of LT. Despite this, there was no difference in HCC recurrence rates post-LT, whether patients achieved SVR pre- or post-LT. Conclusions. These data suggest that HCV eradication pre-LT does not significantly impact waitlist time for HCV+ patients with HCC. HCV eradication does not impact rates of delisting for HCC progression or rates of HCC recurrence post-LT.

Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure used to diagnose and treat a variety of hepatobiliary and pancreatic conditions. ERCP has transitioned from a diagnostic test to a therapeutic intervention, with the complexity of cases becoming more challenging and the possibility of subsequent complications increasing. Previous studies have demonstrated that high volume endoscopists (HVE; >75 ERCP /year) have greater success compared to low volume endoscopists (LVE), despite performing more complex procedures. After our previous study demonstrated the benefit of having ERCP performed by HVE, our site transitioned to all procedures performed by HVE. The aim of our study was to determine if this strategy resulted in improved ERCP outcomes at our centre. A retrospective chart review of all ERCPs completed between September 2014 - September 2016, collecting data on cannulation success rate, ERCP complexity score, and any significant post-ERCP complications. These results were compared to ERCP patient outcomes performed between January 2010 - December 2012 which were completed by mixed volume endoscopists (MVE). From January 2010 - December 2012, six MVE performed a total of 1246 ERCP while only four HVE performed a total of 1385 ERCP from September 2014 to September 2016. Patient demographics were similar between both groups. Successful cannulation was achieved in 92.5% for the HVE group, in comparison to 89.8% for the MVE group (OR 1.40, 95% CI 1.07–1.84, P=0.02), while the overall success rate was 89.2% in the HVE group versus 86.7% for the MVE group (OR 1.27, 95% CI 1.00–1.60, P=0.05). Once adjusted for ERCP complexity, the OR for successful cannulation was 1.32 (95% CI 1.04–1.68, P=0.03), and for successful completion of the procedure was 1.32 (95% CI 1.00–1.74, P=0.05). The rate of unintentional cannulation of the pancreatic duct (PD) was not different between the HVE and MVE groups (18.7% and 17.2%, respectively; OR 1.11, 0.91–1.35, P=0.3); however, the PD injection was lower in the HVE compared to the MVE group (5.4% vs. 9.8, P<0.001). The risk of post-ERCP pancreatitis rates was not different for the HVE and MVE groups after adjustment for complexity score (3.4% vs. 2.9%, OR 1.08, 95% CI 0.80–1.49, P=0.6). The risk of perforation was lower in the group of HVE compared to MVE, after adjusting for complexity score (0.2% vs. 0.6%, OR 0.25, 0.06–0.96, P=0.04). There was no mortality in either group. The outcomes of patients undergoing ERCP at our centre has significantly improved with limiting ERCP to be performed by select HVE. While this data only reflects the experience at a single centre, transitioning complex care of ERCP patients to expert facilities performing HVE may result in improved patients outcomes. None

Our aim was to determine if end-stage liver disease (ESLD) is associated with an attenuated response to vasodilator-stress or dobutamine-stress using 82Rb-PET MPI with blood flow quantification.

Endoscopic retrograde cholangiopancreatography (ERCP) is a common interventional procedure used to diagnose and treat a variety of hepatobiliary and pancreatic conditions. ERCP has transitioned from a diagnostic test to a therapeutic intervention. Previous studies have demonstrated that high volume endoscopists (HVE; >75 ERCP/year) have lower complications compared to low volume endoscopists (LVE), despite performing more complex procedures. After our previous study demonstrated the benefit of having ERCP performed by HVE, our site transitioned to all ERCP being performed by HVE. The aim of our study was to determine if this strategy resulted in improved ERCP outcomes at our centre. A retrospective chart review of all ERCPs completed between 2014 - 2016, collecting data on cannulation success rate, ERCP complexity score, and any significant post-ERCP complications. These results were compared to ERCP patient outcomes performed between 2010 - 2012 which were completed by (mixed volume endoscopists, MVE). From January 2010 - December 2012, 6 MVE performed a total of 1246 ERCP while 4 HVE performed a total of 1385 ERCP from September 2014 to September 2016. Patient demographics were similar between both groups. Complexity score was significantly higher in the HVE compared to the MVE group (2.4±0.8 vs. 2.0±0.8, P<0.001). Successful cannulation was achieved in 92.5% for the HVE group, in comparison to 89.8% for the MVE group (OR 1.40, 95% CI 1.07-1.84, P=0.02), overall success rate was 89.2% in the HVE group versus 86.7% for the MVE group (OR 1.27, 95% CI 1.00-1.60, P=0.05). Once adjusted for ERCP complexity, the OR for successful cannulation was 1.32 (95% CI 1.04-1.68, P=0.03), successful completion of the procedure 1.32 (95% CI 1.00-1.74, P=0.05). Trend toward lower overall complication in the HVE (6.8%) compared to the MVE (8.4%) group (OR 0.76, 95% CI 0.57-1.03, P=0.07). Bleeding rates in the HVE rates were 0.1%, while the mixed group 2.6% (OR 0.05, 95% CI 0.01-0.21, P<0.001). Perforation rates in the HVE rates were 0.2%, while the mixed group 0.6% (OR 0.25, 95% CI 0.06-0.96, P=0.04). Post-ERCP pancreatitis rates was not different for the HVE and MVE groups. The rate of unintentional cannulation of the pancreatic duct was not different between the HVE and MVE groups (18.7% and 17.2%, respectively; OR 1.11, 0.91-1.35, P=0.3); however, the PD injection was lower in the HVE compared to the MVE group (5.4% vs. 9.8, P<0.001). The overall success and complication rate of ERCP at our centre was significantly improved by limiting ERCP to be selectively performed by HVE. Adverse events specifically bleeding and perforation rates were lower when completed by HVE. While this data only reflects the experience at a single centre, transitioning complex care of ERCP patients to expert facilities performing HVE may result in improved patients outcomes.

Background. Since 2002, the Model of End-Stage Liver Disease (MELD) has been used for allocation of liver transplants (LT) in the USA. In Canada, livers were allocated by the CanWAIT algorithm. The aim of this study was to compare the abilities of MELD, Child-Pugh (CP), and CanWAIT status to predict 3-month and 1-year mortality before LT in Canadian patients and to describe the use of MELD in Canada.Methods. Validation of MELD was performed in 320 patients listed for LT in Alberta (1998–2002). In October 2014, a survey of MELD use by Canadian LT centers was conducted.Results. Within 1 year of listing, 47 patients were removed from the waiting list (29 deaths, 18 too ill for LT). Using logistic regression, the MELD and CP were better than the CanWAIT at predicting 3-month (AUROC: 0.79, 0.78, and 0.59;p=0.0002) and 1-year waitlist mortality (AUROC: 0.70, 0.70, and 0.55;p=0.0023). Beginning in 2004, MELD began to be adopted by Canadian LT programs but its use was not standardized.Conclusions. Compared with the CanWAIT system, the MELD score was significantly better at predicting LT waitlist mortality. MELD-sodium (MELD-Na) has now been adopted for LT allocation in Canada.