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IntroductionDonation after circulatory death (DCD) liver transplantation (LT) makes up well less than 1% of all LTs with a Model for End-Stage Liver Disease (MELD)≥35 in the United States. We hypothesized DCD-LT yields acceptable ischemia-reperfusion and reasonable outcomes for recipients with MELD≥35.MethodsWe analyzed recipients with lab-MELD≥35 at transplant within the UCSF (n=41) and the UNOS (n=375) cohorts using multivariate Cox regression and propensity score matching.ResultsIn the UCSF cohort, five-year patient survival was 85% for DCD-LTs and 86% for matched-Donation after Brain Death donors-(DBD) LTs (p=0.843). Multivariate analyses showed that younger donor/recipient age and more recent transplants (2011-2021 versus 1999-2010) were associated with better survival. DCD vs. DBD graft use did not significantly impact survival (HR: 1.2, 95%CI 0.6-2.7). The transaminase peak was approximately doubled, indicating suggesting an increased ischemia-reperfusion hit. DCD-LTs had a median post-LT length of stay of 11 days, and 34% (14/41) were on dialysis at discharge versus 12 days and 22% (9/41) for DBD-LTs. 27% (11/41) DCD-LTs versus 12% (5/41) DBD-LTs developed a biliary complication (p=0.095). UNOS cohort analysis confirmed patient survival predictors, but DCD graft emerged as a risk factor (HR: 1.5, 95%CI 1.3-1.9) with five-year patient survival of 65% versus 75% for DBD-LTs (p=0.016). This difference became non-significant in a sub-analysis focusing on MELD 35-36 recipients. Analysis of MELD≥35 DCD recipients showed that donor age of

BackgroundMost patients are listed for liver transplant (LT) following extensive workup as outpatients ("conventional evaluation"). Some patients undergo urgent evaluation as inpatients after being transferred to a transplant center ("expedited evaluation"). We hypothesized that expedited patients would have inferior survival due to disease severity at the time of transplant and shorter workup time.MethodsPatients who underwent evaluation for LT at our institution between 2012 and 2016 were retrospectively reviewed. The expedited and conventional cohorts were defined as above. Living donor LT recipients, combined liver-kidney recipients, acute liver failure patients, and re-transplant patients were excluded. We compared patient characteristics and overall survival between patients who received a transplant following expedited evaluation and those who did not, and between LT recipients based on expedited or conventional evaluation.ResultsFive-hundred and nine patients were included (110 expedited, 399 conventional). There was no difference in graft or patient survival at 1 year for expedited versus conventional LT recipients. In multivariable analysis of overall survival, only Donor Risk Index (HR 1.97, CI 1.04-3.73, P = .037, per unit increase) was associated with increased risk of death.ConclusionsPatients who underwent expedited evaluation for LT had significant demographic and clinical differences from patients who underwent conventional evaluation, but comparable post-transplant survival.

BackgroundThe use of living donor liver transplantation (LDLT) for primary liver transplantation (LT) may quell concerns about allocating deceased donor organs if the need for retransplantation (re-LT) arises because the primary LT did not draw from the limited organ pool. However, outcomes of re-LT after LDLT are poorly studied. The purpose of this study was to analyze the Adult to Adult Living Donor Liver Transplantation Study (A2ALL) data to report outcomes of re-LT after LDLT, with a focus on long-term survival after re-LT.MethodsA retrospective review of A2ALL data collected between 1998 and 2014 was performed. Patients were excluded if they received a deceased donor LT. Demographic data, postoperative outcomes and complications, graft and patient survival, and predictors of re-LT and patient survival were assessed.ResultsOf the 1065 patients who underwent LDLT during the study time period, 110 recipients (10.3%) required re-LT. In multivariable analyses, hepatitis C virus, longer length of stay at LDLT, hepatic artery thrombosis, biliary stricture, infection, and disease recurrence were associated with an increased risk of re-LT. Patient survival among re-LT patients was significantly inferior to those who underwent primary transplant only at 1 (86% versus 92%), 5 (64% versus 82%), and 10 years (44% versus 68%).ConclusionsApproximately 10% of A2ALL patients who underwent primary LDLT required re-LT. Compared with patients who underwent primary LT, survival among re-LT recipients was worse at 1, 5, and 10 years after LT, and re-LT was associated with a significantly increased risk of death in multivariable modeling (hazard ratios, 2.29; P

BackgroundShare 35 was a policy implemented in 2013 to increase regional sharing of deceased donor livers to patients with model for end-stage liver disease ≥ 35 to decrease waitlist mortality for the sickest patients awaiting liver transplantation (LT). The purpose of this study was to determine whether live donor liver transplantation (LDLT) volume was impacted by the shift in allocation of deceased donor livers to patients with higher model for end-stage liver disease scores.MethodsUsing Network for Organ Sharing/Organ Procurement and Transplantation Network Standard Transplant Analysis and Research files, we identified all adults who received a primary LT between October 1, 2008, and March 31, 2018. LT from October 1, 2008, through June 30, 2013, was designated as the pre-Share 35 era and July 1, 2013, through March 31, 2018, as the post-Share 35 era. Primary outcomes included transplant volumes, graft survival, and patient survival in both eras.ResultsIn total, 48 779 primary adult single-organ LT occurred during the study period (22 255 pre-Share 35, 26 524 post). LDLT increased significantly (6.8% post versus 5.7% pre, P

Living donor liver transplantation (LDLT) enjoys widespread use in Asia, but remains limited to a handful of centers in North America and comprises only 5% of liver transplants performed in the United States. In contrast, living donor kidney transplantation is used frequently in the United States, and has evolved to commonly include paired exchanges, particularly for ABO-incompatible pairs. Liver paired exchange (LPE) has been utilized in Asia, and was recently reported in Canada; here we report the first LPE performed in the United States, and the first LPE to be performed on consecutive days. The LPE performed at our institution was initiated by a nondirected donor who enabled the exchange for an ABO-incompatible pair, and the final recipient was selected from our deceased donor waitlist. The exchange was performed over the course of 2 consecutive days, and relied on the use and compliance of a bridge donor. Here, we show that LPE is feasible at centers with significant LDLT experience and affords an opportunity to expand LDLT in cases of ABO incompatibility or when nondirected donors arise. To our knowledge, this represents the first exchange of its kind in the United States.

ObjectiveTo determine the effects of ESRT (an iteratively adapted and tailored MBI) on perceived stress, executive cognitive function, psychosocial well-being (ie, burnout, mindfulness), and pro-inflammatory gene expression in surgical (ESRT-1) and mixed specialty (ESRT-2) PGY-1 volunteers.Summary of background and dataTailored MBIs have proven beneficial in multiple high-stress and high-performance populations. In surgeons, tailored MBIs have been shown to be feasible and potentially beneficial, but whether mindfulness-based cognitive training can improve perceived stress, executive function, well-being or physiological distress in surgical and nonsurgical trainees is unknown.MethodsIn 2 small single-institution randomized clinical trials, ESRT, a tailored mindfulness-based cognitive training program, was administered and iteratively adapted for first-year surgical (ESRT-1, 8 weekly, 2-hour classes, n = 44) and mixed specialty (ESRT-2, 6 weekly, 90-minute classes, n = 45) resident trainees. Primary and secondary outcomes were, respectively, perceived stress and executive function. Other prespecified outcomes were burnout (assessed via Maslach Burnout Inventory), mindfulness (assessed via Cognitive Affective Mindfulness Scale - Revised), and pro-inflammatory gene expression (assessed through the leukocyte transcriptome profile "conserved transcriptional response to adversity").ResultsNeither version of ESRT appeared to affect perceived stress. Higher executive function and mindfulness scores were seen in ESRT-1, and lower emotional exhaustion and depersonalization scores in ESRT-2, at pre-/postintervention and/or 50-week follow-up (ESRT-1) or at 32-week follow-up (ESRT-2), compared to controls. Pooled analysis of both trials found ESRT-treated participants had reduced pro-inflammatory RNA expression compared to controls.ConclusionsThis pilot work suggests ESRT can variably benefit executive function, burnout, and physiologic distress in PGY-1 trainees, with potential for tailoring to optimize effects.

Background: Scoring systems have been proposed to select donation after circulatory death (DCD) donors and recipients for liver transplantation (LT). We hypothesized that complex scoring systems derived in large datasets might not predict outcomes locally. Methods: Based on 1-year DCD-LT graft survival predictors in multivariate logistic regression models, we designed, validated, and compared a simple index using the University of California, San Francisco (UCSF) cohort (n = 136) and a universal-comprehensive (UC)-DCD score using the United Network for Organ Sharing (UNOS) cohort (n = 5,792) to previously published DCD scoring systems. Results: The total warm ischemia time (WIT)-index included donor WIT (dWIT) and hepatectomy time (dHep). The UC-DCD score included dWIT, dHep, recipient on mechanical ventilation, transjugular-intrahepatic-portosystemic-shunt, cause of liver disease, model for end-stage liver disease, body mass index, donor/recipient age, and cold ischemia time. In the UNOS cohort, the UC-score outperformed all previously published scores in predicting DCD-LT graft survival (AUC: 0.635 vs. ≤0.562). In the UCSF cohort, the total WIT index successfully stratified survival and biliary complications, whereas other scores did not. Conclusion: DCD risk scores generated in large cohorts provide general guidance for safe recipient/donor selection, but they must be tailored based on non-/partially-modifiable local circumstances to expand DCD utilization.

BackgroundSix percent of opioid-naïve patients develop opioid dependence post-operatively. We implemented a protocol in our renal transplant recipients that eliminated opioid patient-controlled analgesia (PCA) and included a multi-modal non-opioid regimen. The purpose of this study was to examine the impact of PCA elimination on opioid requirements at discharge in renal transplant recipients.MethodsWe reviewed adult renal transplant recipients for the three months prior to, and following, the protocol's implementation. Patients with an intra-abdominal transplant, pancreas-renal transplant, or chronic pain were excluded. The number of opioid pills prescribed on the day prior to discharge were categorized as A) 0, B) 1-3, and C) ≥4. Discharge opioid prescriptions were then evaluated based on a recent recommendation that group A receive 0 pills, group B 15 pills, and group C 30 pills, to satisfy the outpatient pain needs of 85% of patients. Pre- and post-intervention metrics were compared using independent t-tests and Chi squared tests.Results150 recipients were included (79 pre-intervention, 71 post; 51% male). PCA use decreased significantly (81% vs. 4.2%, p

BackgroundAlcoholic liver disease (ALD) accounts for 15%-30% of transplants performed in the United States and Europe; however, the data on living donor liver transplantation (LDLT) for ALD remain sparse. The purpose of this study was to examine the outcomes following LDLT for ALD using data from the adult-to-adult living donor liver transplantation (A2ALL) study, which represents the largest Western experience with adult-to-adult LDLT.MethodsA retrospective review of A2ALL data collected between 1998 and 2014 was performed. Patients were excluded if they received a deceased donor liver transplant. Demographic data, postoperative outcomes and complications, graft and patient survival, and predictors of graft and patient survival were assessed.ResultsOf the 1065 patients who underwent LDLT during the study time period, 168 (15.8%) were transplanted for a diagnosis of ALD. Comparing patients who underwent transplant for ALD with those who were transplanted for other etiologies of liver disease, there was no significant difference in graft survival at 1 (88% versus 84%), 5 (76% versus 74%), or 10 years following transplant (55% versus 61%, P = 0.29). Similarly, there was no difference in patient survival at 1 (94% versus 91%), 5 (83% versus 79%), or 10 years following transplant (61% versus 66%, P = 0.32).ConclusionsLDLT for ALD results in excellent 1-, 5-, and 10-year graft and patient survival. Patients with ALD and impaired renal function have a higher risk of graft loss and death. These findings support the notion that early LDLT for patients with ALD may help optimize outcomes.

ImportanceAmong surgical trainees, burnout and distress are prevalent, but mindfulness has been shown to decrease the risk of depression, suicidal ideation, burnout, and overwhelming stress. In other high-stress populations, formal mindfulness training has been shown to improve mental health, yet this approach has not been tried in surgery.ObjectiveTo test the feasibility and acceptability of modified Mindfulness-Based Stress Reduction (MBSR) training during surgical residency.Design, setting, and participantsA pilot randomized clinical trial of modified MBSR vs an active control was conducted with 21 surgical interns in a residency training program at a tertiary academic medical center, from April 30, 2016, to December 2017.InterventionsWeekly 2-hour, modified MBSR classes and 20 minutes of suggested daily home practice over an 8-week period.Main outcomes and measuresFeasibility was assessed along 6 domains (demand, implementation, practicality, acceptability, adaptation, and integration), using focus groups, interviews, surveys, attendance, daily practice time, and subjective self-report of experience.ResultsOf the 21 residents included in the analysis, 13 were men (62%). Mean (SD [range]) age of the intervention group was 29.0 (2.4 [24-31]) years, and the mean (SD [range]) age of the control group was 27.4 (2.1 [27-33]) years. Formal stress-resilience training was feasible through cultivation of stakeholder support. Modified MBSR was acceptable as evidenced by no attrition; high attendance (12 of 96 absences [13%] in the intervention group and 11 of 72 absences [15%] in the control group); no significant difference in days per week practiced between groups; similar mean (SD) daily practice time between groups with significant differences only in week 1 (control, 28.15 [12.55] minutes; intervention, 15.47 [4.06] minutes; P = .02), week 2 (control, 23.89 [12.93] minutes; intervention, 12.61 [6.06] minutes; P = .03), and week 4 (control, 26.26 [13.12] minutes; intervention, 15.36 [6.13] minutes; P = .04); course satisfaction (based on interviews and focus group feedback); and posttraining-perceived credibility (control, 18.00 [4.24]; intervention, 20.00 [6.55]; P = .03). Mindfulness skills were integrated into personal and professional settings and the independent practice of mindfulness skills continued over 12 months of follow-up (mean days [SD] per week formal practice, 3 [1.0]).Conclusions and relevanceFormal MBSR training is feasible and acceptable to surgical interns at a tertiary academic center. Interns found the concepts and skills useful both personally and professionally and participation had no detrimental effect on their surgical training or patient care.Trial registrationClinicalTrials.gov identifier: NCT03141190.

ImportanceAmong surgical trainees, burnout and distress are prevalent, but mindfulness has been shown to decrease the risk of depression, suicidal ideation, burnout, and overwhelming stress. In other high-stress populations, formal mindfulness training has been shown to improve mental health, yet this approach has not been tried in surgery.ObjectiveTo test the feasibility and acceptability of modified Mindfulness-Based Stress Reduction (MBSR) training during surgical residency.Design, setting, and participantsA pilot randomized clinical trial of modified MBSR vs an active control was conducted with 21 surgical interns in a residency training program at a tertiary academic medical center, from April 30, 2016, to December 2017.InterventionsWeekly 2-hour, modified MBSR classes and 20 minutes of suggested daily home practice over an 8-week period.Main outcomes and measuresFeasibility was assessed along 6 domains (demand, implementation, practicality, acceptability, adaptation, and integration), using focus groups, interviews, surveys, attendance, daily practice time, and subjective self-report of experience.ResultsOf the 21 residents included in the analysis, 13 were men (62%). Mean (SD [range]) age of the intervention group was 29.0 (2.4 [24-31]) years, and the mean (SD [range]) age of the control group was 27.4 (2.1 [27-33]) years. Formal stress-resilience training was feasible through cultivation of stakeholder support. Modified MBSR was acceptable as evidenced by no attrition; high attendance (12 of 96 absences [13%] in the intervention group and 11 of 72 absences [15%] in the control group); no significant difference in days per week practiced between groups; similar mean (SD) daily practice time between groups with significant differences only in week 1 (control, 28.15 [12.55] minutes; intervention, 15.47 [4.06] minutes; P = .02), week 2 (control, 23.89 [12.93] minutes; intervention, 12.61 [6.06] minutes; P = .03), and week 4 (control, 26.26 [13.12] minutes; intervention, 15.36 [6.13] minutes; P = .04); course satisfaction (based on interviews and focus group feedback); and posttraining-perceived credibility (control, 18.00 [4.24]; intervention, 20.00 [6.55]; P = .03). Mindfulness skills were integrated into personal and professional settings and the independent practice of mindfulness skills continued over 12 months of follow-up (mean days [SD] per week formal practice, 3 [1.0]).Conclusions and relevanceFormal MBSR training is feasible and acceptable to surgical interns at a tertiary academic center. Interns found the concepts and skills useful both personally and professionally and participation had no detrimental effect on their surgical training or patient care.Trial registrationClinicalTrials.gov identifier: NCT03141190.

Since 2012, the Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) has required transplant centers to record the citizenship residency status of patients undergoing transplantation in the United States. This policy replaced the 5% threshold of the non-US citizen/nonresidents (NC/NR) undergoing organ transplantation that could result in an audit of transplant center activity. Since April 1, 2015, the country of residence for the NC/NR on the waitlist has also been recorded. We analyzed the frequency of NC/NR deceased donor organ transplants and waitlist registrations at all US transplant centers by data provided by UNOS for that purpose to the UNOS Ad Hoc International Relations Committee. During the period of 2013 to 2016, 1176 deceased donor transplants (of all organs) were performed in non-US citizen/non-US resident (NC/NR) candidates (0.54% of the total number of transplants). We focused on high-volume NC/NR transplant centers that performed more than 5% of the deceased donor kidney or liver transplants in NC/NR or whose waitlist registrants exceeded 5% NC/NR. This report was prepared to fulfill the transparency policy of UNOS to assure a public trust in the distribution of organs. When viewed with a public awareness of deceased donor organ shortages, it suggests the need for a more comprehensive understanding of current NC/NR activity in the United States. Patterns of organ specific NC/NR registrations and transplantations at high-volume centers should prompt a review of transplant center practices to determine whether the deceased donor and center resources may be compromised for their US patients.

Alcoholic liver disease (ALD) is now a well-recognized indication for liver transplantation. This paper reviews existing literature on living donor liver transplantation (LDLT) for ALD and presents data from a single, high volume United States liver transplant center.For the literature review, a PubMed search was undertaken using the search terms 'living donor' and 'alcoholic liver disease'. Studies were included that presented outcome data for patients who underwent LDLT for ALD. For the single-center data collection, all patients who underwent LDLT from 2003 to 2016 at our center were reviewed and the data for recipients with ALD was subsequently analyzed and compared with those patients who underwent LDLT for other indications.Of 110 studies that resulted from the PubMed query, only 5 contained data that was relevant to this manuscript. These studies represented data collected from two Asian countries: one single center in Korea and a collection of centers in Japan. The relapse rate following LDLT for ALD ranged from 7.9% to 22%, and pre-transplant abstinence did not impact post-transplant relapse in any of these studies. For the single-center data, of 136 LDLT performed at our institution during the time period, 22 were performed for ALD. There was no difference in 1- or 5-year survival between patients transplanted for ALD and those transplanted for other etiologies (94.7% vs. 93.4%, P = 0.79 and 78.9% vs. 87.5%, P = 0.6).There is a very limited amount of data available on LDLT for ALD. Existing data suggests that LDLT for ALD results in excellent outcomes.Published data on living donor liver transplantation (LDLT) for alcoholic liver disease (ALD) are limited. One- and five-year survival rates range from 82% to 100% and 78% to 87%, respectively. Rates of alcohol relapse following transplant appear low, ranging from 7% to 23%; 6-month abstinence periods prior to LDLT for ALD do not appear to have a significant impact on relapse.

AimsAlcoholic liver disease (ALD) is now a well-recognized indication for liver transplantation. This paper reviews existing literature on living donor liver transplantation (LDLT) for ALD and presents data from a single, high volume United States liver transplant center.MethodsFor the literature review, a PubMed search was undertaken using the search terms 'living donor' and 'alcoholic liver disease'. Studies were included that presented outcome data for patients who underwent LDLT for ALD. For the single-center data collection, all patients who underwent LDLT from 2003 to 2016 at our center were reviewed and the data for recipients with ALD was subsequently analyzed and compared with those patients who underwent LDLT for other indications.ResultsOf 110 studies that resulted from the PubMed query, only 5 contained data that was relevant to this manuscript. These studies represented data collected from two Asian countries: one single center in Korea and a collection of centers in Japan. The relapse rate following LDLT for ALD ranged from 7.9% to 22%, and pre-transplant abstinence did not impact post-transplant relapse in any of these studies. For the single-center data, of 136 LDLT performed at our institution during the time period, 22 were performed for ALD. There was no difference in 1- or 5-year survival between patients transplanted for ALD and those transplanted for other etiologies (94.7% vs. 93.4%, P = 0.79 and 78.9% vs. 87.5%, P = 0.6).ConclusionThere is a very limited amount of data available on LDLT for ALD. Existing data suggests that LDLT for ALD results in excellent outcomes.Short summaryPublished data on living donor liver transplantation (LDLT) for alcoholic liver disease (ALD) are limited. One- and five-year survival rates range from 82% to 100% and 78% to 87%, respectively. Rates of alcohol relapse following transplant appear low, ranging from 7% to 23%; 6-month abstinence periods prior to LDLT for ALD do not appear to have a significant impact on relapse.

BACKGROUND:Burnout among physicians affects mental health, performance, and patient outcomes. Surgery residency is a high-risk time for burnout. We examined burnout and the psychological characteristics that can contribute to burnout vulnerability and resilience in a group of surgical trainees. STUDY DESIGN:An online survey was distributed in September 2016 to all ACGME-accredited general surgery programs. Burnout was assessed with an abbreviated Maslach Burnout Inventory. Stress, anxiety, depression, resilience, mindfulness, and alcohol use were assessed and analyzed for prevalence. Odds ratios (ORs) were used to determine the magnitude of presumed risk and resilience factors. RESULTS:Among 566 surgical residents who participated in the survey, prevalence of burnout was 69%, equally driven by emotional exhaustion and depersonalization. Perceived stress and distress symptoms (depression, suicidal ideation, and anxiety) were notably high across training levels, but improved during lab years. Higher burnout was associated with high stress (OR 7.8; p

BACKGROUND:Burnout among physicians affects mental health, performance, and patient outcomes. Surgery residency is a high-risk time for burnout. We examined burnout and the psychological characteristics that can contribute to burnout vulnerability and resilience in a group of surgical trainees. STUDY DESIGN:An online survey was distributed in September 2016 to all ACGME-accredited general surgery programs. Burnout was assessed with an abbreviated Maslach Burnout Inventory. Stress, anxiety, depression, resilience, mindfulness, and alcohol use were assessed and analyzed for prevalence. Odds ratios (ORs) were used to determine the magnitude of presumed risk and resilience factors. RESULTS:Among 566 surgical residents who participated in the survey, prevalence of burnout was 69%, equally driven by emotional exhaustion and depersonalization. Perceived stress and distress symptoms (depression, suicidal ideation, and anxiety) were notably high across training levels, but improved during lab years. Higher burnout was associated with high stress (OR 7.8; p

BackgroundWith the use of split liver grafts as well as living donor liver transplantation (LDLT) it is imperative to know the minimum graft volume to avoid complications. Most current formulas to predict standard liver volume (SLV) rely on weight-based measures that are likely inaccurate in the setting of cirrhosis. Therefore, we sought to create a formula for estimating SLV without weight-based covariates.MethodsLDLT donors underwent computed tomography scan volumetric evaluation of their livers. An optimal formula for calculating SLV using the anthropomorphic measure thoracoabdominal circumference (TAC) was determined using leave-one-out cross-validation. The ability of this formula to correctly predict liver volume was checked against other existing formulas by analysis of variance. The ability of the formula to predict small grafts in LDLT was evaluated by exact logistic regression.ResultsThe optimal formula using TAC was determined to be SLV = (TAC × 3.5816) - (Age × 3.9844) - (Sex × 109.7386) - 934.5949. When compared to historic formulas, the current formula was the only one which was not significantly different than computed tomography determined liver volumes when compared by analysis of variance with Dunnett posttest. When evaluating the ability of the formula to predict small for size syndrome, many (10/16) of the formulas tested had significant results by exact logistic regression, with our formula predicting small for size syndrome with an odds ratio of 7.94 (95% confidence interval, 1.23-91.36; P = 0.025).ConclusionWe report a formula for calculating SLV that does not rely on weight-based variables that has good ability to predict SLV and identify patients with potentially small grafts.

Background:With the use of split liver grafts as well as living donor liver transplantation (LDLT) it is imperative to know the minimum graft volume to avoid complications. Most current formulas to predict standard liver volume (SLV) rely on weight-based measures that are likely inaccurate in the setting of cirrhosis. Therefore, we sought to create a formula for estimating SLV without weight-based covariates. Methods:LDLT donors underwent computed tomography scan volumetric evaluation of their livers. An optimal formula for calculating SLV using the anthropomorphic measure thoracoabdominal circumference (TAC) was determined using leave-one-out cross-validation. The ability of this formula to correctly predict liver volume was checked against other existing formulas by analysis of variance. The ability of the formula to predict small grafts in LDLT was evaluated by exact logistic regression. Results:The optimal formula using TAC was determined to be SLV = (TAC × 3.5816) - (Age × 3.9844) - (Sex × 109.7386) - 934.5949. When compared to historic formulas, the current formula was the only one which was not significantly different than computed tomography determined liver volumes when compared by analysis of variance with Dunnett posttest. When evaluating the ability of the formula to predict small for size syndrome, many (10/16) of the formulas tested had significant results by exact logistic regression, with our formula predicting small for size syndrome with an odds ratio of 7.94 (95% confidence interval, 1.23-91.36; P = 0.025). Conclusion:We report a formula for calculating SLV that does not rely on weight-based variables that has good ability to predict SLV and identify patients with potentially small grafts.

BackgroundLiving donor liver transplantation (LDLT) has become increasingly common in an effort to increase organ availability for the treatment of end-stage liver disease. Donor safety is a primary concern in LDLT. The majority of complications experienced by living donors are infectious or biliary in nature. The purpose of this paper was to review the existing literature on biliary complications in living donors.MethodsStudies were eligible for inclusion if they were published in English between 2006-present, focused on adult-to-adult LDLT, and were available via PubMed/MEDLINE.ResultsA total of 33 studies reporting outcomes from 12,653 donors (right lobe: 8231, left lobe: 4422) were included. Of 33 studies, 12 reported outcomes from right lobe donors, 1 from left lobe donors, 14 compared left and right, and 6 focused specifically on biliary complications. A total of 830 biliary complications (6.6%) were reported, with 75 donors requiring re-operation for biliary complications and 1 donor death attributed to biliary complications.ConclusionAlthough bile leaks and strictures are still relatively common following living donor hepatectomy, the majority of complications are minor and resolve with conservative measures. Approximately 6% of living donors will experience a biliary complication and, of these 6%, approximately 9% (total of 0.6% of donors) will require operative management of the biliary complication.

BackgroundLiving donor liver transplantation (LDLT) has become increasingly common in an effort to increase organ availability for the treatment of end-stage liver disease. Donor safety is a primary concern in LDLT. The majority of complications experienced by living donors are infectious or biliary in nature. The purpose of this paper was to review the existing literature on biliary complications in living donors.MethodsStudies were eligible for inclusion if they were published in English between 2006-present, focused on adult-to-adult LDLT, and were available via PubMed/MEDLINE.ResultsA total of 33 studies reporting outcomes from 12,653 donors (right lobe: 8231, left lobe: 4422) were included. Of 33 studies, 12 reported outcomes from right lobe donors, 1 from left lobe donors, 14 compared left and right, and 6 focused specifically on biliary complications. A total of 830 biliary complications (6.6%) were reported, with 75 donors requiring re-operation for biliary complications and 1 donor death attributed to biliary complications.ConclusionAlthough bile leaks and strictures are still relatively common following living donor hepatectomy, the majority of complications are minor and resolve with conservative measures. Approximately 6% of living donors will experience a biliary complication and, of these 6%, approximately 9% (total of 0.6% of donors) will require operative management of the biliary complication.

ObjectiveThe purpose of this study was to assess first-year medical students' implicit perceptions of surgeons, focusing on the roles of gender and demeanor (communal = supportive, associated with women; agentic = assertive, associated with men).DesignSurvey study. Each survey had 1 of 8 possible scenarios; all began with a short description of a surgeon who was described as accomplished and well trained, then varied by surgeon gender (male/female), surgeon demeanor (agentic/communal), and type of surgery (breast cancer/lung cancer). Using a 0 to 5 scale, respondents rated their perception of the surgeon through 5 questions. These 5 items were averaged to create a composite perception score scaled from 0 to 5.SettingSurveys were administered at the University of California, San Francisco, and the University of California, Los Angeles.ParticipantsWe administered surveys to 333 first-year medical students who could read English and voluntarily agreed to participate.ResultsA total of 238 students responded (71.5%). They preferred the communal vs agentic surgeon (4.2 ± 0.7 vs 3.9 ± 0.7, p = 0.002) and male medical students perceived surgeons more favorably than female medical students did (4.2 ± 0.6 vs 4.0 ± 0.8, p = 0.036). The preference score did not differ according to surgeon gender (female 4.12 vs male 3.98, p = 0.087). There were no significant interactions between the factors of student gender, surgeon gender, or demeanor. Students who reported an interest in surgery as a career did not perceive surgeons more favorably than the students interested in other fields (4.3 ± 0.7 vs 4.0 ± 0.7 respectively, p = 0.066).ConclusionsBased on our findings, surgeon educators would likely find success in teaching and recruiting medical students by employing a communal demeanor in their interactions with all students, regardless of the students' gender or stated interest in surgery.

ObjectiveThe purpose of this study was to assess first-year medical students' implicit perceptions of surgeons, focusing on the roles of gender and demeanor (communal = supportive, associated with women; agentic = assertive, associated with men).DesignSurvey study. Each survey had 1 of 8 possible scenarios; all began with a short description of a surgeon who was described as accomplished and well trained, then varied by surgeon gender (male/female), surgeon demeanor (agentic/communal), and type of surgery (breast cancer/lung cancer). Using a 0 to 5 scale, respondents rated their perception of the surgeon through 5 questions. These 5 items were averaged to create a composite perception score scaled from 0 to 5.SettingSurveys were administered at the University of California, San Francisco, and the University of California, Los Angeles.ParticipantsWe administered surveys to 333 first-year medical students who could read English and voluntarily agreed to participate.ResultsA total of 238 students responded (71.5%). They preferred the communal vs agentic surgeon (4.2 ± 0.7 vs 3.9 ± 0.7, p = 0.002) and male medical students perceived surgeons more favorably than female medical students did (4.2 ± 0.6 vs 4.0 ± 0.8, p = 0.036). The preference score did not differ according to surgeon gender (female 4.12 vs male 3.98, p = 0.087). There were no significant interactions between the factors of student gender, surgeon gender, or demeanor. Students who reported an interest in surgery as a career did not perceive surgeons more favorably than the students interested in other fields (4.3 ± 0.7 vs 4.0 ± 0.7 respectively, p = 0.066).ConclusionsBased on our findings, surgeon educators would likely find success in teaching and recruiting medical students by employing a communal demeanor in their interactions with all students, regardless of the students' gender or stated interest in surgery.

BackgroundOptimizing the surgeon-nurse relationship to improve interprofessional communication is increasingly recognized as an essential component of patient care. The increasing number of women surgeons has altered the surgeon-nurse dynamic, which has traditionally been a male-female relationship. In particular, this shift has raised the issue of whether implicit perceptions regarding gender and demeanor influence the interactions between surgeons and nurses. Therefore, the purpose of this study was to understand nurses' implicit perceptions of surgeons, with a particular focus on gender and gender-normative demeanor. We defined two types of demeanor: communal, which is classically associated with women and includes being supportive and nurturing, and agentic, which is a male-associated trait that includes being direct and assertive.MethodsWe administered surveys to 1701 nurses at the main campus of our institution. Each survey had one of eight possible scenarios; all began with a short description of a surgeon who was described as accomplished and well-trained, then varied by surgeon gender (male/female), surgeon demeanor (agentic/communal) and type of surgery (breast cancer/lung cancer). Using a 0 to 5 scale, respondents rated their perception of the surgeon through five questions. These five items were averaged to create a composite perception score scaled from 0 to 5.ResultsWe received 493 surveys. The overall average perception score was 3.8±0.99. Respondents had a statistically significant preference for the communal surgeon (4.1±0.91) versus the agentic surgeon (3.6±1.0, p

BackgroundOptimizing the surgeon-nurse relationship to improve interprofessional communication is increasingly recognized as an essential component of patient care. The increasing number of women surgeons has altered the surgeon-nurse dynamic, which has traditionally been a male-female relationship. In particular, this shift has raised the issue of whether implicit perceptions regarding gender and demeanor influence the interactions between surgeons and nurses. Therefore, the purpose of this study was to understand nurses' implicit perceptions of surgeons, with a particular focus on gender and gender-normative demeanor. We defined two types of demeanor: communal, which is classically associated with women and includes being supportive and nurturing, and agentic, which is a male-associated trait that includes being direct and assertive.MethodsWe administered surveys to 1701 nurses at the main campus of our institution. Each survey had one of eight possible scenarios; all began with a short description of a surgeon who was described as accomplished and well-trained, then varied by surgeon gender (male/female), surgeon demeanor (agentic/communal) and type of surgery (breast cancer/lung cancer). Using a 0 to 5 scale, respondents rated their perception of the surgeon through five questions. These five items were averaged to create a composite perception score scaled from 0 to 5.ResultsWe received 493 surveys. The overall average perception score was 3.8±0.99. Respondents had a statistically significant preference for the communal surgeon (4.1±0.91) versus the agentic surgeon (3.6±1.0, p

BackgroundPerceptions underlie bias and drive behavior. This study assessed female surgeons' implicit perceptions of surgeons, with a focus on the roles of sex and demeanor (communal = supportive, associated with women; agentic = assertive, associated with men).MethodsElectronic surveys were administered via the Association of Women Surgeons e-mail listserve to 550 post-training female surgeons. Each survey had one of the 4 possible scenarios that varied by surgeon sex (male/female) and surgeon demeanor (agentic/communal). Respondents rated their perception of the surgeon through 5 questions regarding preference and 5 questions regarding professional opinion (1 to 5 scale).ResultsWe received 212 surveys. In both preference and professional scores, female surgeons were rated significantly higher compared with their male counterparts (4.7 vs 4.4 and 4.3 vs 4.0, respectively). Communal surgeons were rated significantly higher versus agentic surgeons in both scores (4.7 vs 4.4 and 4.6 vs 3.7).ConclusionsFemale surgeons demonstrated a significant preference for female surgeons and for communal surgeons.

BackgroundPerceptions underlie bias and drive behavior. This study assessed female surgeons' implicit perceptions of surgeons, with a focus on the roles of sex and demeanor (communal = supportive, associated with women; agentic = assertive, associated with men).MethodsElectronic surveys were administered via the Association of Women Surgeons e-mail listserve to 550 post-training female surgeons. Each survey had one of the 4 possible scenarios that varied by surgeon sex (male/female) and surgeon demeanor (agentic/communal). Respondents rated their perception of the surgeon through 5 questions regarding preference and 5 questions regarding professional opinion (1 to 5 scale).ResultsWe received 212 surveys. In both preference and professional scores, female surgeons were rated significantly higher compared with their male counterparts (4.7 vs 4.4 and 4.3 vs 4.0, respectively). Communal surgeons were rated significantly higher versus agentic surgeons in both scores (4.7 vs 4.4 and 4.6 vs 3.7).ConclusionsFemale surgeons demonstrated a significant preference for female surgeons and for communal surgeons.

BackgroundAs more women become surgeons, knowledge of patient perceptions is necessary to educate this new pool of surgeons on how to maximize patient trust and foster the optimal surgeon-patient relationship.Materials and methodsPatients in a general medicine clinic in San Francisco were surveyed. Study respondents read one of the eight short scenarios that differed by surgeon gender, surgery type (lung cancer versus breast cancer), and surgeon demeanor (more masculine--agentic versus more feminine--communal). In all scenarios, the surgeon was described as accomplished and well trained. After reading the short description, respondents rated five items from 0-5, which were averaged to create a measure of preference.ResultsBased on the 476 completed surveys, respondents did not have a significant preference for either female or male surgeons (P = 0.76). We found a significant interaction in respondent choice between the surgeon demeanor and the type of surgery (P < 0.05). Respondents preferred an agentic surgeon for lung cancer surgery and a communal surgeon for breast cancer surgery regardless of surgeon or respondent gender. No other interactions or main effects were statistically significant.ConclusionsOur respondents did not overtly prefer a surgeon based on gender, which suggests that patients may not contribute to the traditional gender biases reported by female surgeons. Further work needs to be done to determine if our results can be replicated in different geographic regions and if there is gender stereotyping within the field of surgery.

BackgroundAs more women become surgeons, knowledge of patient perceptions is necessary to educate this new pool of surgeons on how to maximize patient trust and foster the optimal surgeon-patient relationship.Materials and methodsPatients in a general medicine clinic in San Francisco were surveyed. Study respondents read one of the eight short scenarios that differed by surgeon gender, surgery type (lung cancer versus breast cancer), and surgeon demeanor (more masculine--agentic versus more feminine--communal). In all scenarios, the surgeon was described as accomplished and well trained. After reading the short description, respondents rated five items from 0-5, which were averaged to create a measure of preference.ResultsBased on the 476 completed surveys, respondents did not have a significant preference for either female or male surgeons (P = 0.76). We found a significant interaction in respondent choice between the surgeon demeanor and the type of surgery (P < 0.05). Respondents preferred an agentic surgeon for lung cancer surgery and a communal surgeon for breast cancer surgery regardless of surgeon or respondent gender. No other interactions or main effects were statistically significant.ConclusionsOur respondents did not overtly prefer a surgeon based on gender, which suggests that patients may not contribute to the traditional gender biases reported by female surgeons. Further work needs to be done to determine if our results can be replicated in different geographic regions and if there is gender stereotyping within the field of surgery.

BackgroundSuccessful left lateral segment (sectionectomy) and right trisegmentectomy (trisectionectomy) split-liver transplantation (SLT) have been achieved. However, there are few reports of the use of true right/left splitting in SLT.MethodsA single-centre retrospective review of true right/left ex vivo split-liver transplants performed during the period 1993-2010 was conducted. Nine cadaveric liver grafts underwent splitting and the resultant 18 allografts were used in transplants performed at the study centre.ResultsIn the nine right lobe recipients, 10-year patient and graft survival rates were both 74%. There were no vascular complications, one biliary complication and one re-exploration. In the nine left lobe recipients, 10-year patient and graft survival rates were 78% and 66%, respectively. Postoperative complications included six biliary complications, four of which required surgical revision and all of which occurred within 5 months of transplantation, and two vascular complications, including one early hepatic artery thrombosis (HAT) and one late HAT, one of which required retransplantation. Five left lobe recipients required re-exploration, and one patient developed small-for-size syndrome following SLT, which resolved with conservative measures.ConclusionsTrue right/left ex vivo SLT remains a viable option for facilitating the expansion of the adult cadaver donor pool and allows for excellent patient and graft survival. Postoperative morbidity remains high, especially in recipients of the left lobe graft, and must be balanced with the benefits to be derived from transplant.

BackgroundSuccessful left lateral segment (sectionectomy) and right trisegmentectomy (trisectionectomy) split-liver transplantation (SLT) have been achieved. However, there are few reports of the use of true right/left splitting in SLT.MethodsA single-centre retrospective review of true right/left ex vivo split-liver transplants performed during the period 1993-2010 was conducted. Nine cadaveric liver grafts underwent splitting and the resultant 18 allografts were used in transplants performed at the study centre.ResultsIn the nine right lobe recipients, 10-year patient and graft survival rates were both 74%. There were no vascular complications, one biliary complication and one re-exploration. In the nine left lobe recipients, 10-year patient and graft survival rates were 78% and 66%, respectively. Postoperative complications included six biliary complications, four of which required surgical revision and all of which occurred within 5 months of transplantation, and two vascular complications, including one early hepatic artery thrombosis (HAT) and one late HAT, one of which required retransplantation. Five left lobe recipients required re-exploration, and one patient developed small-for-size syndrome following SLT, which resolved with conservative measures.ConclusionsTrue right/left ex vivo SLT remains a viable option for facilitating the expansion of the adult cadaver donor pool and allows for excellent patient and graft survival. Postoperative morbidity remains high, especially in recipients of the left lobe graft, and must be balanced with the benefits to be derived from transplant.

Living donor liver transplantation (LDLT), originally used in children with left lateral segment grafts, has been expanded to adults who require larger grafts to support liver function. Most adult LDLT procedures have been performed with right lobe grafts, and this means a significant risk of morbidity for the donors. To minimize the donor risk for adults, there is renewed interest in smaller left lobe grafts. The smaller graft size increases the recipient risk in the form of small-for-size syndrome (SFSS) and essentially transfers the risk from the donor to the recipient. We review the donor and recipient risks of LDLT and pay particular attention to the different types of liver grafts and the use of graft inflow modification to ameliorate the risk of SFSS. Finally, a new metric is proposed for quantifying the recipient benefit in exchange for a specific donor risk.

Living donor liver transplantation (LDLT), originally used in children with left lateral segment grafts, has been expanded to adults who require larger grafts to support liver function. Most adult LDLT procedures have been performed with right lobe grafts, and this means a significant risk of morbidity for the donors. To minimize the donor risk for adults, there is renewed interest in smaller left lobe grafts. The smaller graft size increases the recipient risk in the form of small-for-size syndrome (SFSS) and essentially transfers the risk from the donor to the recipient. We review the donor and recipient risks of LDLT and pay particular attention to the different types of liver grafts and the use of graft inflow modification to ameliorate the risk of SFSS. Finally, a new metric is proposed for quantifying the recipient benefit in exchange for a specific donor risk.

IntroductionCavernous hemangiomas represent the most common benign primary hepatic neoplasm, often being incidentally detected. Although the majority of hepatic hemangiomas remain asymptomatic, symptomatic hepatic hemangiomas can present with abdominal pain, hemorrhage, biliary compression, or a consumptive coagulopathy. The optimal surgical management of symptomatic hepatic hemangiomas remains controversial, with resection, enucleation, and both deceased donor and living donor liver transplantation having been reported.Case reportWe report the case of a patient found to have a unique syndrome of multiorgan cavernous hemangiomatosis involving the liver, lung, omentum, and spleen without cutaneous involvement. Sixteen years following her initial diagnosis, the patient suffered from intra-abdominal hemorrhage due to her giant cavernous hepatic hemangioma. Evidence of continued bleeding, in the setting of Kasabach-Merritt Syndrome and worsening abdominal compartment syndrome, prompted MELD exemption listing. The patient subsequently underwent emergent liver transplantation without complication.ConclusionAlthough cavernous hemangiomas represent the most common benign primary hepatic neoplasm, hepatic hemangioma rupture remains a rare presentation in these patients. Management at a center with expertise in liver transplantation is warranted for those patients presenting with worsening DIC or hemorrhage, given the potential for rapid clinical decompensation.

IntroductionCavernous hemangiomas represent the most common benign primary hepatic neoplasm, often being incidentally detected. Although the majority of hepatic hemangiomas remain asymptomatic, symptomatic hepatic hemangiomas can present with abdominal pain, hemorrhage, biliary compression, or a consumptive coagulopathy. The optimal surgical management of symptomatic hepatic hemangiomas remains controversial, with resection, enucleation, and both deceased donor and living donor liver transplantation having been reported.Case reportWe report the case of a patient found to have a unique syndrome of multiorgan cavernous hemangiomatosis involving the liver, lung, omentum, and spleen without cutaneous involvement. Sixteen years following her initial diagnosis, the patient suffered from intra-abdominal hemorrhage due to her giant cavernous hepatic hemangioma. Evidence of continued bleeding, in the setting of Kasabach-Merritt Syndrome and worsening abdominal compartment syndrome, prompted MELD exemption listing. The patient subsequently underwent emergent liver transplantation without complication.ConclusionAlthough cavernous hemangiomas represent the most common benign primary hepatic neoplasm, hepatic hemangioma rupture remains a rare presentation in these patients. Management at a center with expertise in liver transplantation is warranted for those patients presenting with worsening DIC or hemorrhage, given the potential for rapid clinical decompensation.