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Background: Despite advances in preoperative staging, cancer of the pancreatic head is frequently found to be unresectable at laparotomy. We sought to identify potential areas of improvement in preoperative staging.Methods: We performed a retrospective institutional review of patients referred for resection of cancer of the pancreatic head over a 2-year period. The primary outcome was the rate of metastasis or unresectable disease found at laparotomy in patients who were booked for pancreaticoduodenectomy with curative intent.Results: During the study period, 133 patients were referred with suspected cancer of the pancreatic head. All underwent preoperative computed tomography scanning. Twenty-four also underwent preoperative endoscopic ultrasonography (EUS) and 23 also underwent magnetic resonance imaging (MRI). In total, 78 patients were deemed not to be candidates for surgery, leaving 55 patients with potentially resectable cancer who were scheduled for pancreaticoduodenectomy. Of these, 32 patients (58%) underwent successful resection with curative intent, and 23 patients (42%) were found to have metastatic or locally advanced disease not identified by preoperative staging. Reasons for nonresectability were metastases (9 patients, 16%), vascular involvement (12 patients, 22%) and mesentery involvement (2 patients, 4%). One patient had a diagnostic laparoscopy immediately before planned open exploration and was found to have peritoneal seeding precluding curative resection. Of the patients who underwent EUS, 14 were not surgical candidates because of locally advanced tumours. Ten patients were offered surgery with curative intent, and 5 patients (50%) were found have unresectable tumours (4 metastatic, 1 locally advanced). Of the patients who underwent MRI, 11 were offered surgery, and 5 (45%) had unresectable tumours (2 metastatic, 3 locally advanced disease).Conclusion: In our institution, preoperative staging for cancer of the pancreatic head misses a substantial number of metastatic and unresectable disease. There is clearly room for improvement, and newer technologies should be evaluated to enhance the detection of metastatic and locally advanced disease to prevent unnecessary laparotomy. [ABSTRACT FROM AUTHOR]

Background: Gastrointestinal (GI) complications following coronary artery bypass grafting (CABG), although infrequent, are associated with significant morbidity and mortality. It has been suggested that systemic inflammatory response plays an important role in these complications. Cardiopulmonary bypass (CPB) is well known to cause increased systemic inflammation, and therefore it has been proposed that performing CABG using an off-pump technique could substantially minimize the risk of GI complications. Prolonged CPB duration has been shown to be an independent predictor of GI complications; however, the effect of avoiding CPB altogether through off-pump procedures has not been thoroughly examined. We sought to compare the incidence of GI complications in patients undergoing on-pump and off-pump CABG.Methods: We analyzed prospectively entered data on 2451 patients who underwent isolated CABG between January 2000 and October 2004. We compared GI complication rates in 5 predetermined areas (GI bleed, ileus, pancreatitis, ischemic bowel and cholecystitis) among patients who had on-pump CABG with those of patients who had off-pump CABG. We also compared in-hospital mortality due to these complications between the 2 groups.Results: We compared data for a total of 2010 patients in the on-pump group and 441 in the off-pump group. In the on-pump group, 30 (1.49%) patients experienced GI complications compared with 4 (0.91%) in the off-pump group (p = 0.34). Gastrointestinal bleed was the most common complication in the off-pump group. Eight patients in the on-pump group experienced ischemic bowels compared with no patients in the off-pump group. Six patients (0.3%) in the on-pump group died from GI complications, whereas no patients in the off-pump group died from such complications (p = 0.25).Conclusion: We found no significant difference in the total number of GI complications between the off-pump and on-pump groups; however, trends could be seen in the types of GI complications that occurred in the 2 groups. Owing to the relatively infrequent occurrence of GI complications, a larger scale study would be beneficial to determine whether the differences observed would be significant. [ABSTRACT FROM AUTHOR]

A duodenal adenocarcinoma arising from the junction of the second and third portion of the duodenum, which was resected by pancreas-sparing duodenectomy, is reported. The completely obstructing tumour was circumferential and measured 6.5cm x 3.5cm x 1.0 cm. There was no evidence of pancreas invasion, nor any lymph node metastasis. Pancreas-sparing duodenectomy was performed, with dissection of the pancreaticoduodenal lymph nodes. The proximal duodenum was transected just distal to the ampula of Vater and jejunum was transected just distal to the ligament of Treitz. A hand-sewn side-to-side anastomosis for the duodenojejunostomy was performed. There were no postoperative complications. Pathology reported a duodenal adenocarcinoma resected with negative margins. Pancreaticoduodenectomy is the treatment of choice for a duodenal adenocarcinoma, however, pancreas-sparing duodenectomy may be a safe alternative for duodenal tumours not involving the 2nd portion, especially in elderly patients with multiple medical comorbidities. [ABSTRACT FROM PUBLISHER]

Background: The availability of in situ normothermic regional perfusion (NRP) or ex situ normothermic machine perfusion (NMP) has revolutionized donation after circulatory death (DCD) liver transplant (LT). While some have suggested that NRP and NMP may represent competing technologies for DCD LT, there are many scenarios where these technologies can function in a complementary manner., Methods: Between January 2022 and March 2024, 83 DCD LTs were performed using NRP (62 NRP alone and 21 NRP + NMP) and were compared with 297 static cold storage (SCS) DCD LTs. NRP + NMP was used in scenarios with (1) long travel distances, (2) complicated transplant recipients, or (c) the need for additional liver graft recovery in "marginal" cases., Results: Ischemic cholangiopathy was lower in the NRP alone group (0%) and the NRP + NMP group (0%) compared with the SCS group (16.8; P < 0.001 and P = 0.04, respectively). In addition, early allograft dysfunction, number of packed red blood cells transfused, and acute kidney injury were lower in the NRP alone and NRP + NMP groups compared with the SCS group. Graft survival was higher in cases where NRP was used than in cases where SCS was used (P = 0.016). In all the cases where lactate remained elevated at the end of NRP (mean 8.2 ± 2.0), it ultimately normalized at the end of NMP (0.92 ± 0.56)., Conclusions: The present study demonstrates lower rates of ischemic cholangiopathy and improved graft survival with NRP alone or NRP + NMP compared with SCS when using liver grafts from DCD donors. It also demonstrates that excellent outcomes can be achieved with sequential NRP + NMP in cases with prolonged travel distances, complicated recipients, or when there is a need for additional liver recovery in "marginal" cases., Competing Interests: Dr Dhanireddy is on the Advisory Board for OrganOx, and Dr Subramanian is a paid consultant for OrganOx. The other authors declare no funding or conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

There is a paucity of data on the impact of cold ischemia time before the initiation of normothermic machine perfusion (NMP), particularly in more susceptible organs such as livers from donation after circulatory death (DCD) donors. The present analysis aimed to investigate the impact of prolonged time from cross-clamp until NMP start on early allograft dysfunction and other peri-liver transplant (LT) outcomes. All DCD LT performed and placed on NMP at Mayo Clinic Arizona, Florida, and Rochester from January 2022 to March 2024 were included. The decision was made a priori to divide the population into 2 groups based on terciles: typical cross-clamp to on-pump time (lower 2 terciles) versus prolonged cross-clamp to on-pump time (upper tercile; >2 h 45.6 min). Three hundred eighty-four DCD LT undergoing NMP met the inclusion criteria. The rate of early allograft dysfunction was significantly higher in the prolonged cross-clamp to on-pump group (51.2%) compared to the typical cross-clamp to on-pump group (37.6%) ( p = 0.01). The prolonged cross-clamp to on-pump group also had higher rates of acute kidney injury and the number of packed red blood cells transfused during LT. No significant difference in ischemic cholangiopathy (2.4% vs. 3.1%; p = 0.68) or graft survival at 12 months was seen between the prolonged cross-clamp to on-pump and typical cross-clamp to on-pump group, respectively. Following cross-clamp, DCD liver grafts should be placed on the NMP pump as quickly as is safely and logistically possible. In cases where delays are unavoidable, such as waiting for biopsy results or liver reallocation with another center, acceptable results can still be achieved, and therefore, livers with prolonged times should still be used., (Copyright © 2024 American Association for the Study of Liver Diseases.)

Importance: Despite the unmet need for donor organs, organ use from donation after circulatory determination of death (DCD) donors has been limited by inferior transplant outcomes. Normothermic regional perfusion (NRP) improves recipient outcomes and organ utilization from DCD donors. There is variability in NRP policies and experience among US organ procurement organizations (OPOs)., Objectives: To determine OPO experience, identify operational inconsistencies, and explore needs related to NRP., Design, Setting, and Participants: This survey study included 55 OPOs in the US that had recovered DCD organs and completed a survey on operational, administrative, and educational components related to NRP in November to December 2023. Data analysis was performed from February to April 2024., Main Outcome and Measures: The primary outcome was the number of OPOs participating in and/or anticipating NRP participation. Secondary outcomes were NRP implementation barriers, OPO education practices, and future needs regarding consensus NRP recommendations and standards., Results: Of 55 respondents, 11 (20%) were chief executive officers, 8 (15%) were chief operating officers, and 36 (65%) were medical directors or chief clinical officers. Forty-nine OPOs facilitated NRP cases: 26 OPOs (53%) facilitated both thoracoabdominal NRP (TA-NRP) and abdominal NRP (A-NRP) cases, 16 OPOs (33%) facilitated only TA-NRP, and 7 OPOs (14%) facilitated only A-NRP. OPOs reported 606 NRP cases (421 TA-NRP [69%], 185 A-NRP [31%]); median (range) case experience was 8 (1-52). Fifty-two of 55 OPOs (95%) thought standardized guidance documents would be helpful. All 49 OPOs facilitated NRP at a transplant center's request; 39 (80%) had NRP initiated by a nonlocal transplant center. Twenty-three of 49 OPOs (47%) participated in NRP without a policy and without a policy pending approval. Positive donor hospital feedback was received by 29 OPOs (59%), primarily focused on increased organs transplanted and prerecovery communication. Allocation challenges were experienced by 21 OPOs (43%); their median (range) case volume was higher than those with no reported allocation challenges (11 [3-52] vs 6.5 [1-29]; P = .03). Eleven OPOs (22%) had incorporated NRP into general donor hospital education., Conclusions: In this survey study of US OPOs, wide variation existed with respect to NRP experience and practice. Allocation challenges occurred more frequently with increased NRP experience. NRP guidelines and standardization were desired by most OPOs to decrease allocation challenges and maximize the gift of organ donation.

Obesity is a risk factor for kidney, liver, heart, and pulmonary diseases, as well as failure. Solid organ transplantation remains the definitive treatment for the end-stage presentation of these diseases. Among many criteria for organ transplant, efficient management of obesity is required for patients to acquire transplant eligibility. End-stage organ failure and obesity are 2 complex pathologies that are often entwined. Metabolic and bariatric surgery before, during, or after organ transplant has been studied to determine the long-term effect of bariatric surgery on transplant outcomes. In this review, a multidisciplinary group of surgeons from the Society of American Gastrointestinal and Endoscopic Surgeons and the American Society for Transplant Surgery presents the current published literature on metabolic and bariatric surgery as a therapeutic option for patients with obesity awaiting solid organ transplantation. This manuscript details the most recent recommendations, pharmacologic considerations, and psychological considerations for this specific cohort of patients. Since level one evidence is not available on many of the topics covered by this review, expert opinion was implemented in several instances. Additional high-quality research in this area will allow for better recommendations and, therefore, treatment strategies for these complex patients., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: Hepatic venous transplant anastomotic pressure gradient measurement and transjugular liver biopsy are commonly used in clinical decision-making in patients with suspected anastomotic hepatic venous outflow obstruction. This investigation aimed to determine if sinusoidal dilatation and congestion on histology are predictive of hepatic venous anastomotic outflow obstruction, and if it can help select patients for hepatic vein anastomosis stenting., Materials and Methods: This is a single-center retrospective study of 166 transjugular liver biopsies in 139 patients obtained concurrently with transplant venous anastomotic pressure gradient measurement. Demographic characteristics, laboratory parameters, procedure and clinical data, and histology of time-zero allograft biopsies were analyzed., Results: No relationship was found between transplant venous anastomotic pressure gradient and sinusoidal dilatation and congestion (P = 0.92). Logistic regression analysis for sinusoidal dilatation and congestion confirmed a significant relationship with reperfusion/preservation injury and/or necrosis of the allograft at time-zero biopsy (OR 6.6 [1.3-33.1], P = 0.02)., Conclusion: There is no relationship between histologic sinusoidal dilatation and congestion and liver transplant hepatic vein anastomotic gradient. In this study group, sinusoidal dilatation and congestion is a nonspecific histopathologic finding that is not a reliable criterion to select patients for venous anastomosis stenting., (© 2024. Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE).)

As an alternative to static cold storage (SCS), advanced perfusion techniques such as normothermic regional perfusion and ex-situ perfusion (normothermic or hypothermic) have emerged as a way to improve the ischemic injury suffered by donation after circulatory death (DCD) livers. Multiple studies have been published that have demonstrated superior post-DCD liver transplant outcomes when using advanced perfusion compared with SCS. In particular, these studies have shown lower rates of ischemic cholangiopathy with advanced perfusion. In addition to the improved post-liver transplant outcomes, studies have also demonstrated higher rates of liver utilization from DCD donors when advanced perfusion is used compared with SCS. Given the high rates of graft loss in patients who develop ischemic cholangiopathy, the significant reduction seen in DCD donor livers that have undergone advanced perfusion represents a key step in more broad utilization of these livers. With such compelling evidence from multiple trials, it seems reasonable to ask the question: should advanced perfusion be the standard of care for DCD liver transplant?, Competing Interests: Declaration of competing interest The author of this manuscript has no conflicts of interest to disclose, as described by the American Journal of Transplantation., (Copyright © 2024 American Society of Transplantation & American Society of Transplant Surgeons. Published by Elsevier Inc. All rights reserved.)

Importance: Normothermic regional perfusion (NRP) is an emerging recovery modality for transplantable allografts from controlled donation after circulatory death (cDCD) donors. In the US, only 11.4% of liver recipients who are transplanted from a deceased donor receive a cDCD liver. NRP has the potential to safely expand the US donor pool with improved transplant outcomes as compared with standard super rapid recovery (SRR)., Objective: To assess outcomes of US liver transplants using controlled donation after circulatory death livers recovered with normothermic regional perfusion vs standard super rapid recovery., Design, Setting, and Participants: This was a retrospective, observational cohort study comparing liver transplant outcomes from cDCD donors recovered by NRP vs SRR. Outcomes of cDCD liver transplant from January 2017 to May 2023 were collated from 17 US transplant centers and included livers recovered by SRR and NRP (thoracoabdominal NRP [TA-NRP] and abdominal NRP [A-NRP]). Seven transplant centers used NRP, allowing for liver allografts to be transplanted at 17 centers; 10 centers imported livers recovered via NRP from other centers., Exposures: cDCD livers were recovered by either NRP or SRR., Main Outcomes and Measures: The primary outcome was ischemic cholangiopathy (IC). Secondary end points included primary nonfunction (PNF), early allograft dysfunction (EAD), biliary anastomotic strictures, posttransplant length of stay (LOS), and patient and graft survival., Results: A total of 242 cDCD livers were included in this study: 136 recovered by SRR and 106 recovered by NRP (TA-NRP, 79 and A-NRP, 27). Median (IQR) NRP and SRR donor age was 30.5 (22-44) years and 36 (27-49) years, respectively. Median (IQR) posttransplant LOS was significantly shorter in the NRP cohort (7 [5-11] days vs 10 [7-16] days; P < .001). PNF occurred only in the SRR allografts group (n = 2). EAD was more common in the SRR cohort (123 of 136 [56.1%] vs 77 of 106 [36.4%]; P = .007). Biliary anastomotic strictures were increased 2.8-fold in SRR recipients (7 of 105 [6.7%] vs 30 of 134 [22.4%]; P = .001). Only SRR recipients had IC (0 vs 12 of 133 [9.0%]; P = .002); IC-free survival by Kaplan-Meier was significantly improved in NRP recipients. Patient and graft survival were comparable between cohorts., Conclusion and Relevance: There was comparable patient and graft survival in liver transplant recipients of cDCD donors recovered by NRP vs SRR, with reduced rates of IC, biliary complications, and EAD in NRP recipients. The feasibility of A-NRP and TA-NRP implementation across multiple US transplant centers supports increasing adoption of NRP to improve organ use, access to transplant, and risk of wait-list mortality.

On June 3, 2023, the American Society of Transplant Surgeons convened a meeting in San Diego, California to (1) develop a consensus statement with supporting data on the ethical tenets of thoracoabdominal normothermic regional perfusion (NRP) and abdominal NRP; (2) provide guidelines for the standards of practice that should govern thoracoabdominal NRP and abdominal NRP; and (3) develop and implement a central database for the collection of NRP donor and recipient data in the United States. National and international leaders in the fields of neuroscience, transplantation, critical care, NRP, Organ Procurement Organizations, transplant centers, and donor families participated. The conference was designed to focus on the controversial issues of neurological flow and function in donation after circulatory death donors during NRP and propose technical standards necessary to ensure that this procedure is performed safely and effectively. This article discusses major topics and conclusions addressed at the meeting., Competing Interests: E.A.P. is the current President of the American Society of Transplant Surgeons. The other authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: The authors declare no funding or conflicts of interest.

In situ abdominal normothermic regional perfusion (A-NRP) has been used for liver transplantation (LT) with donation after circulatory death (DCD) liver grafts in Europe with excellent results; however, adoption of A-NRP in the United States has been lacking. The current report describes the implementation and results of a portable, self-reliant A-NRP program in the United States. Isolated abdominal in situ perfusion with an extracorporeal circuit was achieved through cannulation in the abdomen or femoral vessels and inflation of a supraceliac aortic balloon and cross-clamp. The Quantum Transport System by Spectrum was used. The decision to use livers for LT was made through an assessment of perfusate lactate (q15min). From May to November 2022, 14 A-NRP donation after circulatory death procurements were performed by our abdominal transplant team (N = 11 LT, N = 20 kidney transplants, and 1 kidney-pancreas transplant). The median A-NRP run time was 68 minutes. None of the LT recipients had post-reperfusion syndrome, nor were there any cases of primary nonfunction. All livers were functioning well at the time of maximal follow-up with zero cases of ischemic cholangiopathy. The current report describes the feasibility of a portable A-NRP program that can be used in the United States. Excellent short-term post-transplant results were achieved with both livers and kidneys procured from A-NRP., (Copyright © 2023 American Association for the Study of Liver Diseases.)

Competing Interests: The author declares no funding or conflicts of interest.

Normothermic regional perfusion (NRP) has gained widespread adoption in multiple European countries. The aim of this study was to examine the influence of thoracoabdominal-NRP (TA-NRP) on the utilization and outcomes of liver, kidney, and pancreas transplantation in the United States., Methods: Using the US national registry data between 2020 and 2021, donation after circulatory death (DCD) donors were separated into 2 groups: DCD with TA-NRP and without TA-NRP. There were 5234 DCD donors; among them 34 donors were with TA-NRP. After 1:4 propensity score matching, the utilization rates were compared between DCD with and without TA-NRP., Results: Although the utilization rates of kidney and pancreas were comparable ( P  = 0.71 and P  = 0.06, 94.1% versus 95.6% and 8.8% versus 2.2%, respectively), that of liver in DCD with TA-NRP was significantly higher ( P  < 0.001; 70.6% versus 39.0%). Among 24 liver transplantations, 62 kidney transplantations, and 3 pancreas transplantations from DCD with TA-NRP, there were 2 liver grafts and 1 kidney graft that failed within 1 y after transplantation., Conclusions: TA-NRP in the United States significantly increased the utilization rate of abdominal organs from DCD donors with comparable outcomes after transplantation. Increasing use of NRP may expand the donor pool without compromising transplant outcomes., Competing Interests: The authors declare no funding or conflicts of interest., (Copyright © 2023 The Author(s). Transplantation Direct. Published by Wolters Kluwer Health, Inc.)

The American Society of Transplant Surgeons supports efforts to increase the number of organs that are critically needed for patients desperately awaiting transplantation. In the United States, transplantation using organs procured from donation after circulatory death (DCD) donors has continued to increase in number. Despite these increases, substantial variability in the utilization and practices of DCD transplantation still exists. To improve DCD organ utilization, it is important to create a set of best practices for DCD recovery. The following recommendations aim to provide guidance on contemporary issues surrounding DCD organ procurement in the United States. A work group was composed of members of the American Society of Transplant Surgeon Scientific Studies Committee and the Thoracic Organ Transplantation Committee. The following topics were identified by the group either as controversial or lacking standardization: prewithdrawal preparation, definition of donor warm ischemia time, DCD surgical technique, combined thoracic and abdominal procurements, and normothermic regional perfusion. The proposed recommendations were classified on the basis of the grade of available evidence and the strength of the recommendation. This information should be valuable for transplant programs as well as for organ procurement organizations and donor hospitals as they develop robust DCD donor procurement protocols., (Copyright © 2022 American Society of Transplantation & American Society of Transplant Surgeons. Published by Elsevier Inc. All rights reserved.)

While adoption of machine perfusion technologies into clinical practice in the United States has been much slower than in Europe, recent changes in the transplant landscape as well as device availability following FDA approval have paved the way for rapid growth. Machine perfusion may provide one mechanism to maximize the utilization of potential donor liver grafts. Indeed, multiple studies have shown increased organ utilization with the implementation of technologies such as ex-situ normothermic machine perfusion (NMP), ex-situ hypothermic machine perfusion (HMP) and in-situ normothermic regional perfusion (NRP). The current review describes the history and development of machine perfusion utilization in the Unites States along with future directions. It also describes the differences in landscape between Europe and the United States and how this has shaped clinical application of these technologies.

With donation after circulatory death (DCD) liver transplantation (LT), the goal of the recipient implantation procedure is to minimize surgical complexity to avoid a tenuous environment for an already marginal graft. The presence of portal vein thrombosis (PVT) at the time of LT adds surgical complexity, yet' to date, no studies have investigated the utilization of DCD liver grafts for patients with PVT., Methods: All DCD LT performed at Mayo Clinic-Florida, Mayo Clinic-Arizona, and Mayo Clinic-Rochester from 2006 to 2020 were reviewed (N = 771). Patients with PVT at the time of transplant were graded using Yerdel classification. A 1:3 propensity match between patients with PVT and those without PVT was performed., Results: A total of 91 (11.8%) patients with PVT undergoing DCD LT were identified. Grade I PVT was present in 62.6% of patients, grade II PVT in 27.5%, grade III in 8.8%, and grade 4 in 1.1%. At the time of LT, thromboendovenectomy was performed in 89 cases (97.8%). There was no difference in the rates of early allograft dysfunction (43.2% versus 52.4%; P = 0.13) or primary nonfunction (1.1% versus 1.1%; P = 0.41) between the DCD PVT and DCD without PVT groups, respectively. The rate of ischemic cholangiopathy was not significantly different between the DCD PVT (11.0%) and DCD without PVT groups (10.6%; P = 0.92). Graft ( P = 0.58) and patient survival ( P = 0.08) were similar between the 2 groups. Graft survival at 1-, 3-, and 5-y was 89.9%, 84.5%, and 79.3% in the DCD PVT group., Conclusions: In appropriately selected recipients with grades I-II PVT, DCD liver grafts can be utilized safely with excellent outcomes., Competing Interests: The authors declare no funding or conflicts of interest., (Copyright © 2022 The Author(s). Transplantation Direct. Published by Wolters Kluwer Health, Inc.)

Purpose: To verify the correlation between yttrium-90 glass microsphere radiation segmentectomy treatment intensification of hepatocellular carcinoma (HCC) and complete pathologic necrosis (CPN) at liver transplantation., Methods: A retrospective, single center, analysis of patients with HCC who received radiation segmentectomy prior to liver transplantation from 2016 to 2021 was performed. The tumor treatment intensification cohort (n = 38) was prescribed radiation segmentectomy as per response recommendations identified in a previously published baseline cohort study (n = 37). Treatment intensification and baseline cohort treatment parameters were compared for rates of CPN. Both cohorts were then combined for an overall analysis of treatment parameter correlation with CPN., Results: Sixty-three patients with a combined 75 tumors were analyzed. Specific activity, dose, and treatment activity were significantly higher in the treatment intensification cohort (all p < 0.01), while particles per cubic centimeter of treated liver were not. CPN was achieved in 76% (n = 29) of tumors in the treatment intensification cohort compared to 49% (n = 18) in the baseline cohort (p = 0.013). The combined cohort CPN rate was 63% (n = 47). ROC analysis showed that specific activity ≥ 327 Bq (AUC 0.75, p < 0.001), dose ≥ 446 Gy (AUC 0.69, p = 0.005), and treatment activity ≥ 2.55 Gbq (AUC 0.71, p = 0.002) were predictive of CPN. Multivariate logistic regression demonstrated that a specific activity ≥ 327 Bq was the sole independent predictor of CPN (p = 0.013)., Conclusion: Radiation segmentectomy treatment intensification for patients with HCC prior to liver transplantation increases rates of CPN. While dose strongly correlated with pathologic response, specific activity was the most significant independent radiation segmentectomy treatment parameter associated with CPN., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To investigate the outcomes of radiation segmentectomy (RS) versus standard-of-care surgical resection (SR)., Materials and Methods: A multisite, retrospective analysis of treatment-naïve patients who underwent either RS or SR was performed. The inclusion criteria were solitary hepatocellular carcinoma ≤8 cm in size, Eastern Cooperative Oncology Cohort performance status of 0-1, and absence of macrovascular invasion or extrahepatic disease. Target tumor and overall progression, time to progression (TTP), and overall survival rates were assessed. Outcomes were censored for liver transplantation., Results: A total of 123 patients were included (RS, 57; SR, 66). Tumor size, Child-Pugh class, albumin-bilirubin score, platelet count, and fibrosis stage were significantly different between cohorts (P ≤ .01). Major adverse events (AEs), defined as grade ≥3 per the Clavien-Dindo classification, occurred in 0 patients in the RS cohort vs 13 (20%) patients in the SR cohort (P < .001). Target tumor progression occurred in 3 (5%) patients who underwent RS and 5 (8%) patients who underwent SR. Overall progression occurred in 19 (33%) patients who underwent RS and 21 (32%) patients who underwent SR. The median overall TTP was 21.9 and 29.4 months after RS and SR, respectively (95% confidence interval [CI], 15.5-28.2 and 18.5-40.3, respectively; P = .03). Overall TTP subgroup analyses showed no difference between treatment cohorts with fibrosis stages 3-4 (P = .26) and a platelet count of <150 × 10 9 /L (P = .29). The overall progression hazard ratio for RS versus SR was not significant per the multivariate Cox regression analysis (1.16; 95% CI, 0.51-2.63; P = .71). The median overall survival was not reached for either of the cohorts. Propensity scores were calculated but were too dissimilar for analysis., Conclusions: RS and SR were performed in different patient populations, which limits comparison. RS approached SR outcomes, with a lower incidence of major AEs, in patients who were not eligible for hepatectomy., (Copyright © 2022 SIR. Published by Elsevier Inc. All rights reserved.)

Background: As the number of donation after circulatory death (DCD) liver transplants (LTs) performed in the United States continues to increase annually, there has been interest by policy makers to develop a more robust exception point safety net for patients who develop ischemic cholangiopathy (IC) following DCD LT. As such, there is a need for better understanding of the clinical course and long-term outcomes in patients who develop IC, as well as determining if IC can be classified into distinct categories with distinctly different clinical outcomes., Methods: All DCD LT performed at Mayo Clinic Florida, Mayo Clinic Arizona, and Mayo Clinic Rochester from January 1999 to March 2020 were included (N = 770). Outcomes were compared between 4 distinct radiologic patterns of IC: diffuse necrosis, multifocal progressive, confluence dominant, and minor form., Results: In total, 88 (11.4%) patients developed IC, of which 42 (5.5%) were listed for retransplantation of liver (ReLT). Patients with diffuse necrosis and multifocal progressive patterns suffered from frequent hospital admissions for cholangitis in the first year following DCD LT (median 3 and 2), were largely stent dependent (100% and 85.7%), and almost universally required ReLT. Patients with confluence dominant disease were managed with multiple stents and frequently recovered, ultimately becoming stent free without need for ReLT. Patients with the minor form IC did well with limited need for stent placement or repeat procedures and did not require ReLT. Graft survival was different between the 4 distinct IC patterns (P < 0.001)., Conclusions: The present analysis provides a detailed analysis on the natural history and clinical course of IC. Patients developing IC can be classified into 4 distinct patterns with distinct clinical courses., Competing Interests: The authors declare no funding or conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Liver transplantation (LT) is an effective strategy for patients with unresectable hepatocellular carcinoma (HCC). To qualify for standardized LT model for end-stage liver disease exception points, the United Network for Organ Sharing National Liver Review Board (NLRB) requires that the presenting and final HCC tumor burden be within the University of California San Francisco criteria, which were recently expanded (within expanded UCSF [W-eUCSF]). Current NLRB criteria may be too restrictive because it has been shown previously that the initial burden does not predict LT failure when tumors downstage to UCSF. This study aims to assess LT outcomes for HCC initially presenting beyond expanded UCSF (B-eUCSF) criteria in a large multicenter collaboration., Study Design: Comparisons of B-eUCSF and W-eUCSF candidates undergoing LT at seven academic institutions between 2001 and 2017 were made from a multi-institutional database. Survival outcomes were compared by Kaplan-Meier and Cox regression analyses., Results: Of 1,846 LT recipients with HCC, 86 (5%) met B-eUCSF criteria at initial presentation, with the remainder meeting W-eUCSF criteria. Despite differences in tumor burden, B-eUCSF candidates achieved comparable 1-, 5- and 10-year overall (89%, 70%, and 55% vs 91%, 74%, and 60%, respectively; p = 0.2) and disease-free (82%, 60%, and 53% vs 89%, 71%, and 59%, respectively; p = 0.07) survival to patients meeting W-eUCSF criteria after LT. Despite increased tumor recurrence in B-eUCSF vs W-eUCSF patients (24% vs 10%, p = 0.0002), post-recurrence survival was similar in both groups (p = 0.69)., Conclusion: Transplantation for patients initially presenting with HCC B-eUSCF criteria offers a survival advantage similar to those with tumors meeting W-eUCSF criteria at presentation. The current NLRB policy is too stringent, and considerations to expand criteria should be discussed., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Opioids are associated with negative transplant outcomes. We sought to identify patient and center effects on over-prescribing of opioids (> 200 OME (oral morphine equivalents))., Study Design: Clinical and opioid prescription data (2014-2017) were collected from three academic transplant centers for kidney (KT), liver (LT), and simultaneous liver-kidney transplant (SLK) patients. Multivariable models were used to identify predictors of opioid over-prescribing at discharge and the occurrence of refill prescriptions at 90 days., Results: Three-thousand seven-hundred and two patients underwent transplant in the cohort (KT: n = 2358, LT: n = 1221, SLK: n = 123). More than 80% of recipients were over-prescribed opioids at discharge (Median OME (mOME) = 300 (IQR 225-375). LT and SLK had the largest prescription size (LT mOME 338 (IQR 300-450); SLK mOME 338 (IQR 225-450) and refill rate (LT: 64%, SLK 59%) (all, P < .001). Multivariable analysis indicated that transplant center was a significant predictor of opioid over-prescription after KT and LT (all, P < .001); older age (in KT) and length of stay (LOS) (in LT) were protective factors (both, P < .05). Refill occurrence was associated with initial prescription size and was reduced by older age and initial LOS (all, P < .05)., Conclusions: The wide variation in opioid prescribing patterns has implications for transplant practice innovation, guideline development, and further study., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Pre-liver transplantation (LT) renal dysfunction is associated with poor post-LT survival. We studied whether early allograft dysfunction (EAD) modifies this association. Data on 2,856 primary LT recipients who received a transplant between 1998 and 2018 were retrospectively reviewed. Patients who died within the first post-LT week or received multiorgan transplants and previous LT recipients were excluded. EAD was defined as (1) total bilirubin ≥ 10 mg/dL on postoperative day (POD) 7, (2) international normalized ratio ≥1.6 on POD 7, and/or (3) alanine aminotransferase or aspartate aminotransferase ≥2000 IU/mL in the first postoperative week. Pre-LT renal dysfunction was defined as serum creatinine >1.5 mg/dL or on renal replacement therapy at LT. Patients were divided into 4 groups according to pre-LT renal dysfunction and post-LT EAD development. Recipients who had both pre-LT renal dysfunction and post-LT EAD had the worst unadjusted 1-year, 3-year, and 5-year post-LT patient and graft survival, whereas patients who had neither renal dysfunction nor EAD had the best survival (P < 0.001). After adjusting for multiple factors, the risk of death was significantly higher only in those with both pre-LT renal dysfunction and post-LT EAD (adjusted hazard ratio [aHR], 2.19; 95% confidence interval [CI], 1.58-3.03; P < 0.001), whereas those with renal dysfunction and no EAD had a comparable risk of death to those with normal kidney function at LT (aHR, 1.12; 95% CI, 0.86-1.45; P = 0.41). Results remained unchanged when pre-LT renal dysfunction was redefined using different glomerular filtration rate cutoffs. Pre-LT renal dysfunction negatively impacts post-LT survival only in patients who develop EAD. Livers at higher risk of post-LT EAD should be used with caution in recipients with pre-LT renal dysfunction., (Copyright © 2021 by the American Association for the Study of Liver Diseases.)

Introduction and Objectives: Renal dysfunction before liver transplantation (LT) is associated with higher post-LT mortality. We aimed to study if this association still persisted in the contemporary transplant era., Materials and Methods: We retrospectively reviewed data on 2871 primary LT performed at our center from 1998 to 2018. All patients were listed for LT alone and were not considered to be simultaneous liver-kidney (SLK) transplant candidates. SLK recipients and those with previous LT were excluded. Patients were grouped into 4 eras: era-1 (1998-2002, n = 488), era-2 (2003-2007, n = 889), era-3 (2008-2012, n = 703) and era-4 (2013-2018, n = 791). Pre-LT renal dysfunction was defined as creatinine (Cr) >1.5 mg/dl or on dialysis at LT. The effect of pre-LT renal dysfunction on post-LT patient survival in each era was examined using Kaplan Meier estimates and univariate and multivariate Cox proportional hazard analyses., Results: Pre-LT renal dysfunction was present in 594 (20%) recipients. Compared to patients in era-1, patients in era-4 had higher Cr, lower eGFR and were more likely to be on dialysis at LT (P < 0.001). Pre-LT renal dysfunction was associated with worse 1, 3 and 5-year survival in era-1 and era-2 (P < 0.005) but not in era-3 or era-4 (P = 0.13 and P = 0.08, respectively). Multivariate analysis demonstrated the lack of independent effect of pre-LT renal dysfunction on post-LT mortality in era-3 and era-4. A separate analysis using eGFR <60 mL/min/1.73 m 2 at LT to define renal dysfunction showed similar results., Conclusions: Pre-LT renal dysfunction had less impact on post-LT survival in the contemporary transplant era., (Copyright © 2021 Fundación Clínica Médica Sur, A.C. Published by Elsevier España, S.L.U. All rights reserved.)

Donation after circulatory death (DCD) grafts are commonly used in liver transplantation. Attributable to the additional ischemic event during the donor warm ischemia time (DWIT), DCD grafts carry an increased risk for severe ischemia/reperfusion injury and postoperative complications, such as ischemic cholangiopathy. The actual ischemia during DWIT depends on the course of vital parameters after withdrawal of life support and varies widely between donors. The ischemic period (functional DWIT) starts when either Spo2 or blood pressure drop below a certain point and lasts until the start of cold perfusion during organ retrieval. Over the years, multiple definitions and thresholds of functional DWIT duration have been used. The International Liver Transplantation Society organized a Consensus Conference on DCD, Liver Preservation, and Machine Perfusion on January 31, 2020 in Venice, Italy. The aim of this conference was to reach consensus about various aspects of DCD liver transplantation in context of currently available evidence. Here we present the recommendations with regards to the definitions used for DWIT and functional DWIT, the importance of vital parameters after withdrawal of life support, and acceptable thresholds of duration of functional DWIT to proceed with liver transplantation., Competing Interests: The authors declare no funding or conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To evaluate the pathologic outcomes of hepatocellular carcinoma (HCC) treated with Yttrium-90 radiation segmentectomy using glass microspheres prior to liver transplantation and explore parameters associated with pathologic necrosis., Materials and Methods: A single-institution retrospective analysis of HCC patients who received radiation segmentectomy prior to liver transplantation from November 2016 to May 2020 was performed. Patients were included if the treatment angiosome encompassed the entire tumor and could be correlated with available gross pathology. Archived histology slides were reviewed for percentage of pathologic necrosis. Thirty-three patients with 37 tumors were evaluated. The median tumor size was 2.3 cm (range, 1-6.7 cm)., Results: All tumors received a single treatment. The median time from radiation segmentectomy to transplantation was 206 days (range, 58-550 days). Objective response per Modified Response Evaluation Criteria in Solid Tumors (mRECIST) was 92% (complete response, 76%; partial response, 16%). A total of 68% (n = 25) of tumors demonstrated ≥99% pathologic necrosis. Complete pathologic necrosis was present in 53% and 75% of tumors treated with >190 Gy (n = 18) and >500 Gy (n = 8) single-compartment Medical Internal Radiation Dose, respectively. Complete response per mRECIST, posttreatment angiosome T1 hypointensity, dose >190 Gy, microsphere specific activity >297 Bq, and a longer time between treatment and transplant were associated with ≥99% tumor necrosis (P < .05). No posttransplant tumor recurrences occurred within a median follow-up of 604 days (range, 138-1,223 days)., Conclusions: Radiation segmentectomy can serve as an ablative modality for the treatment of HCC prior to liver transplant., (Copyright © 2020 SIR. Published by Elsevier Inc. All rights reserved.)

The number of steatotic deceased donor livers encountered has continued to rise as a result of the obesity epidemic. Little is known about the histological characteristics of moderately macrosteatotic livers over time in the recipient following liver transplantation (LT). All recipients undergoing LT at Mayo Clinic Florida with donor livers with moderate macrosteatosis (30%-60%) from 2000-2017 were identified (n = 96). Routine protocol liver biopsies were performed 1-week and 6-months following LT. All liver donor and protocol biopsies were read by an experienced liver pathologist. Of the 96 moderate macrosteatosis LTs, 70 recipients had post-LT protocol liver biopsies available and comprised the study cohort. Median donor allograft macrosteatosis at the time of transplant was 33% (IQR, 30%-40%) compared with 0% (IQR, 0%-2%) at 1-week (P < 0.001) and 0% (IQR, 0%-0%) at 6-months (P < 0.001) following LT. Biopsies at 1-week post-LT displayed pericentral necrosis in 57.1% of recipients and lipopeliosis in 34.3% of recipients. In the 6-month post-LT biopsies, cholestasis was seen in 3 (4.3%) of the recipients, whereas grade 2 fibrosis was seen in 6 recipients (8.6%). Graft survival at 5 years in the present cohort was 74.0%. Moderate macrosteatosis (30%-60%) in the donor allograft demonstrates complete reversal on liver biopsies performed as early as 7 days following LT and remains absent at 6-months following LT. Both pericentral necrosis and lipopeliosis are common features on day 7 biopsies. Despite these encouraging findings, the perioperative risks of using these livers (postreperfusion cardiac arrest and primary nonfunction) should not be understated. Long-term graft survival is acceptable in patients who are able to overcome the immediate perioperative risk of using moderately steatotic donor livers., (Copyright © 2021 by the American Association for the Study of Liver Diseases.)

Better understanding of how to utilize donation after circulatory death (DCD) liver grafts has resulted in improved national outcomes and expansion in the number of DCD liver transplants (LTs). This improvement has been driven by better donor and recipient matching, careful evaluation of hemodynamics during withdrawal of life support, and refinement of the procurement operation. Changes to liver allocation likely will result in increased utilization of DCD liver grafts. Ischemic cholangiopathy remains the Achilles heel of DCD LTs and, although rates have fallen with improved protocols, a certain rate likely is unavoidable. This review discusses contemporary issues with DCD LTs., Competing Interests: Disclosure None of the authors have any conflict of interest to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Donation after circulatory death (DCD) heart transplantation is currently being performed in the United States as part of a clinical trial. As with all donor procurements, effective coordination between all involved teams is vital for successful organ recovery and maximal utilization of donor organs. The current discussion relays a viewpoint on combined DCD liver and heart donor procurement. Key issues highlighted include the vital importance of donor warm ischemia time (DWIT) on outcome for both recipients as well as issues pertaining to DWIT that may arise when performing combined DCD liver and heart donor procurement., (© 2020 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Objective: Solid organ transplant (SOT) recipients have moderately increased risk of pancreatic adenocarcinoma (PAC). We evaluated the incidence and survival of PAC in 2 cohorts and aimed to identify potential risk factors., Methods: This study performed a retrospective cohort analysis. Cohort A was extracted from the United Network of Organ Sharing data set and cohort B from SOT recipients evaluated at 3 Mayo Clinic transplant centers. The primary outcome was age-adjusted annual incidence of PAC. Descriptive statistics, hazard ratios, and survival rates were compared., Results: Cohort A and cohort B included 617,042 and 29,472 SOT recipients, respectively. In cohort A, the annual incidence rate was 12.78 per 100,000 in kidney-pancreas, 13.34 in liver, and 21.87 in heart-lung transplant recipients. Receiving heart-lung transplant, 50 years or older, and history of cancer (in either recipient or donor) were independent factors associated with PAC. Fifty-two patients developed PAC in cohort B. Despite earlier diagnosis (21.15% with stage I-II), survival rates were similar to those reported for sporadic (non-SOT) patients., Conclusions: We report demographic and clinical risk factors for PAC after SOT, many of which were present before transplant and are common to sporadic pancreatic cancer. Despite the diagnosis at earlier stages, PAC in SOT portends a very poor survival., Competing Interests: J.E.C. received a travel grant from Abbvie, Inc, and minor food and beverage from Boston Scientific and Cook Medical. M.B.W. is a consultant at Virgo, Inc, Cosmo/Aries Pharmaceuticals, Anx Robotica (2019), and Covidien; received research grants from Fujifilm, Boston Scientific, Olympus, Medtronic, Ninepoint Medical, and Cosmo/Aries Pharmaceuticals; and received stock/stock options from Virgo, Inc. M.B.W. does consulting on behalf of Mayo Clinic: GI Supply (2018), EndoKey, Endostart, and Boston Scientific and received minor food and beverage from Synergy Pharmaceuticals, Boston Scientific, and Cook Medical. The other authors declare no conflict of interests., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The impact of additional resection for positive proximal bile duct margins during hepatic resection of hilar cholangiocarcinoma (HCCA) on survival and disease progression remains unclear. We asked how re-resection of positive proximal bile duct margins affected outcomes., Methods: Patients undergoing resection between 1993-2017 were reviewed. Both frozen section and final margin status were reviewed. Overall survival was the primary outcome., Results: 153 patients underwent surgical resection for HCCA. Median survival (months) for initial margin negative (M-), margin-positive to margin-negative (M+/M-) and margin-positive to margin-positive (M+/M+) was 45, 33, and 35 months respectively. Nodal metastases increased with margin positivity: 32% with M-, 49% with M+/M- and 63% with M+/M+ (p = 0.016). Local/regional progression more frequently occurred in M+/M- (27.3%) and M+/M+ (33.3%) patients (M+/M- vs. M-: p = 0.41, M+/M+ vs. M-: p = 0.27). Patients receiving postoperative chemotherapy were 33% M-, 46% M+/M- and 63% in M+/M+. Postoperative radiation was used in 13% of M-, 31% of M+/M- and 63% of M+/M+. Most frequent initial recurrences were within the liver and hepaticojejunostomy site., Conclusion: Competing risk for systemic disease based on primary characteristics of HCCA outweighs the impact of re-resection to achieve R0 status. Improved survival will likely depend on future regional and systemic therapy., (Copyright © 2020. Published by Elsevier Ltd.)

Sleeve gastrectomy (SG) at the time of liver transplant (LT) has been argued to decrease resource utilization. However, larger studies examining outcomes are lacking. We aim to determine the outcomes of simultaneous SG and LT compared to LT alone. This is a retrospective cohort study using the 2011-2017 National Inpatient Sample (NIS). The primary outcome was the odds of inpatient mortality in patients undergoing simultaneous SG and LT compared with LT alone. Secondary outcomes included inpatient morbidity, resource utilization, hospital length of stay (LOS), and inflation-adjusted total hospital costs and charges. A total of 45 361 patients underwent LT in the study period, 49 underwent simultaneous SG. Patients undergoing simultaneous LT and SG had lower crude mortality (0.0%) compared to LT alone (2.97%; P = 0.52). There were no statistically significant differences in morbidity, resource utilization, and hospital costs and charges. Patients undergoing simultaneous LT and SG did not have significantly different mortality rates, morbidity, resource utilization, or LOS during the index admission when compared to LT alone. SG may be feasible at the time of LT in very carefully selected patients. Studies should focus in determining which patients are the optimal candidates to undergo simultaneous LT and SG., (© 2020 Steunstichting ESOT. Published by John Wiley & Sons Ltd.)

Background: Given the potentially additive risk from using donor livers that are both steatotic and from a donation after circulatory death (DCD) donor, there is a paucity of data on the outcome of DCD liver transplantation (LT) utilizing livers with macrosteatosis., Methods: All DCD LT performed at Mayo Clinic-Florida, Mayo Clinic-Arizona, and Mayo Clinic-Rochester from 1999 to 2019 were included (N = 714). Recipients of DCD LT were divided into 3 groups: those with moderate macrosteatosis (30%-60%), mild macrosteatosis (5%-30%), and no steatosis (<5%)., Results: Patients with moderate macrosteatosis had a higher rate of postreperfusion syndrome (PRS; 53.9% vs 26.2%; P = .002), postreperfusion cardiac arrest (7.7% vs 0.3%; P < .001), primary nonfunction (PNF; 7.7% vs 1.0%; P = .003), early allograft dysfunction (EAD; 70.8% vs 45.6% and 8.3%; P = .02), and acute kidney injury (AKI; 39.1% vs 19.4%; P = .02) than patients with no steatosis. No difference in any of the perioperative complications was seen between the mild macrosteatosis and the no steatosis groups except for the rate of EAD (56.8% vs 45.6%; P = .04). No difference in ischemic cholangiopathy (IC), vascular thrombosis/stenosis or graft, and patient survival was seen between the 3 groups., Conclusion: DCD donors with mild macrosteatosis < 30% can be utilized with no increase in perioperative complications and similar patient and graft survival compared to DCD donors with no steatosis. When utilizing DCD donors with moderate macrosteatosis higher rates of PRS, PNF, postreperfusion cardiac arrest, EAD, and AKI should be anticipated., (© 2020 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Donation after circulatory death (DCD) donors represent a potential means to help address the disparity between the number of patients awaiting liver transplantation (LT) and the availability of donor livers. While initial enthusiasm for DCD LT was high in the early 2000s, early reports of high rates of biliary complications and inferior graft survival resulted in reluctance among many transplant centers to use DCD liver grafts. As with all innovations in transplant practice, there is undoubtedly a learning curve associated with the optimal utilization of liver grafts from DCD donors. More contemporary data has demonstrated that results with DCD LT are improving and the number of DCD LT performed annually has been steadily increasing. In this concise review, potential mechanisms of injury for DCD livers are discussed along with strategies that have been employed in clinical practice to improve DCD LT outcomes., Competing Interests: None of the authors have any conflict of interest to disclose., (Thieme. All rights reserved.)

Background: Aortohepatic conduits (AHCs) are valuable alternatives when conventional hepatic artery anastomoses are not possible. However, AHCs have earlier and higher occlusion rates and reduced graft and patient survival. While endovascular therapy is safe and effective for conventional anastomotic stenoses, data on AHC stenoses are limited. This study reviewed outcomes for endovascular management of AHC stenosis at a single liver transplant center., Methods: A retrospective review of a prospectively maintained database was performed on the endovascular management of AHC stenosis between January 1, 2000, and December 31, 2016. Medical records, laboratory data, and imaging were analyzed for technical and hemodynamic success, primary and assisted primary patency, and patient and graft survival., Results: Seven patients underwent angioplasty a median of 142 days after transplant, and 2 required reintervention. The primary patency rate was 67% at 6 months and 22% at 1 year. The assisted primary patency rate was 83% at 6 months and 42% at 1, 3, and 5 years. Patient and graft survival were 86% at 6 months and 71%, 57%, and 38% at 1, 3, and 5 years, respectively. Four conduits were patent at last follow-up. There were no major adverse events after angioplasty. One reintervention was complicated by acute AHC thrombosis after stenting, causing biliary necrosis, sepsis, and death. There was no 30-day mortality, retransplant, or surgical revascularization because of endovascular intervention., Conclusions: Endovascular treatment of AHC stenosis appears to be safe with a high technical success rate but lower long-term patency than standard hepatic arterial anastomoses., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Previous large registry studies have demonstrated inferior outcomes for simultaneous liver-kidney transplantation (SLKT) recipients of grafts from donation after circulatory death (DCD) donors compared with those from donation after brain death (DBD) donors in the era from 2000 to 2010. Given the improving national results in liver transplantation alone using grafts from DCD donors, the present study aimed to investigate if results with DCD-SLKT have improved in the modern era. Patients undergoing SLKT between 2000 and 2018 were obtained from the United Network for Organ Sharing Standard Analysis and Research file and divided into 2 eras based on the date of SLKT: era 1 (2000-2010) and era 2 (2011-2018). Improvement in DCD-SLKT patient, liver graft, and kidney graft survival rates was seen between era 1 and era 2 (P < 0.001). Concurrently, there was a decrease in the proportion of critically ill (P = 0.02) and retransplant (P = 0.006) candidates undergoing DCD-SLKT. When DCD-SLKT in era 2 was compared with a propensity-matched cohort of DBD-SLKT in era 2, no differences in patient (P = 0.99), liver graft (P = 0.19), or kidney graft (P = 0.90) survival were observed. In addition, both bilirubin (0.5 versus 0.5 mg/dL; P = 0.86) and creatinine (1.2 versus 1.2 mg/dL; P = 0.68) at last follow-up were not different between the DCD-SLKT and DBD-SLKT patients in era 2. In conclusion, in the most recent era, patients undergoing DCD-SLKT were able to achieve similar outcomes compared with matched patients undergoing DBD-SLKT. DCD-SLKT represents a viable option for appropriately selected recipients., (Copyright © 2019 by the American Association for the Study of Liver Diseases.)

Purpose of Review: The transplant community continues to look for ways to help address the discordance between donor liver graft availability and patients on the liver transplant waiting list. Donation after circulatory death (DCD) donor livers represents one potential means to help address this discordance. The present review describes the changing landscape of DCD liver transplantation (LT)., Recent Findings: The number of DCD LTs performed annually within the USA has continued to grow on an annual basis. Importantly, national data has demonstrated that outcomes with DCD LT have been improving. This improvement has been driven by better understanding of how to successfully utilize these organs through better donor and recipient matching and careful evaluation of both hemodynamics during withdrawal of life support and the refinement of the procurement operation., Summary: Despite these improvements in outcome, ischemic cholangiopathy (IC) continues to be the Achilles heel of DCD LT. Emerging technologies such as various forms of machine perfusion may allow for reduction of complications and better prognostication of the risk associated with DCD liver grafts., Competing Interests: Conflict of InterestThe authors declare that they have no conflict of interest., (© Springer Nature Switzerland AG 2020.)