Background: Robotic living donor hepatectomy offers potential advantages but has been limited to high-volume centers, primarily in Asia and the Middle East. We report our experience establishing a robotic living donor right hepatectomy program in a U.S. center with low LDLT volume and no prior laparoscopic donor hepatectomy experience and analyze early outcomes. Methods: This retrospective cohort study analyzed 37 living donor right hepatectomies (13 robotic [including one open conversion], 24 open) performed between June 2022 and February 2024. Results: The robotic group had longer operative times (median [range], 451 [374–568] minutes vs 368 [276–421] minutes; P < 0.001) but less blood loss (median [range], 200 [50–700] mL vs 900 [300–2500] mL; P < 0.001). One case required unplanned open conversion due to gas embolism. Two hematomas/bleeding (Clavien–Dindo grade IIIB) occurred in the robotic group, but no biliary complications. Comprehensive Complication Index, liver function tests, and hospital stays were similar between the two groups, with no 90-day graft failure/mortality. Conclusion: With extensive surgical experience in both open donor hepatectomy and robotic surgery, along with meticulous preparation as a team, U.S. centers with lower LDLT volume and no laparoscopic experience can safely implement robotic living donor right hepatectomy, achieving comparable short-term outcomes to the open approach. Further research on long-term outcomes and donor quality of life is necessary.

Despite improvements in short-term and long-term outcomes of liver transplant patients, the discrepancy between the number of available livers and transplant candidates continues to increase. The use of expanded criteria donors is one strategy that can be used to address donor shortages. In recent years, preservation strategies such as normothermic machine perfusion (NMP) have been explored to improve the preservation of organs and test their viability before transplantation. We reviewed the recent literature and trials assessing the use of NMP in the setting of liver transplantation. Multiple feasibility trials have demonstrated the clinical prospect of NMP and proved its numerous advantages compared to conventional static cold storage. These advantages include preservation and viability assessment of high-risk donor allografts and grafts that would have otherwise been discarded. This review aims to address the topic of liver NMP in the setting of current and future applications in the setting of extended criteria donor grafts.

Liver transplantation is the most effective treatment for end-stage liver disease. Despite improvements in surgical techniques, transplant rejection remains a significant concern. The liver is considered an immune-privileged organ due to its unique microenvironment and complex interactions among various cell types. Alloimmune responses mediated by T cells and antigen-presenting cells (APCs) play crucial roles in transplant rejection. The liver’s dual blood supply and unique composition of its sinusoidal endothelial cells (LSECs), Kupffer cells (KCs), hepatocytes, and hepatic stellate cells (HSCs) contribute to its immune privilege. Alloantigen recognition by T cells occurs through direct, indirect, and semidirect pathways, leading to acute cellular rejection (ACR) and chronic rejection. ACR is a T cell-mediated process that typically occurs within the first few weeks to months after transplantation. Chronic rejection, on the other hand, is a gradual process characterized by progressive fibrosis and graft dysfunction, often leading to graft loss. Acute antibody-mediated rejection (AMR) is less common following surgery compared to other solid organ transplants due to the liver’s unique anatomy and immune privilege. However, when it does occur, AMR can be aggressive and lead to rapid graft dysfunction. Despite improvements in immunosuppression, rejection remains a challenge, particularly chronic rejection. Understanding the mechanisms of rejection and immune tolerance, including the roles of regulatory T cells (Tregs) and hepatic dendritic cells (DCs), is crucial for improving transplant outcomes. Strategies to induce immune tolerance, such as modulating DC function or promoting Treg activity, hold promise for reducing rejection and improving long-term graft survival. This review focuses on the liver’s unique predisposition to rejection and tolerance, highlighting the roles of individual cell types in these processes. Continued research into the mechanisms of alloimmune responses and immune tolerance in liver transplantation is essential for developing more effective therapies and improving long-term outcomes for patients with end-stage liver disease.

Background and Objectives: Hepatic resection offers promising outcomes for patients with hepatocellular carcinoma (HCC) but can be constrained by factors like patient suitability. Continuous advancements in laparoscopic and robotic technologies have made minimally invasive hepatectomies (MIHs) a viable alternative to open hepatectomies with benefits in terms of recovery and complications. Materials and Methods: We completed a retrospective review on 138 HCC patients who underwent OH or MIH between 2010 and 2020 at the Hume-Lee Transplant Center. Univariate and multivariate analyses were completed on demographic, clinical, and tumor-specific data to assess the impact of these variables on overall and disease-free survival at 1, 3, and 5 years. Preoperative metrics like length of hospital stay (LOS) and operation duration were also evaluated. Results: Of the 109 OH and 29 MIH patients, MIH patients demonstrated shorter LOS and operative times. However, overall survival (OS) and disease-free survival (DFS) were similar between groups, with no significant variations in 1-, 3-, and 5-year survival rates. Age > 60 years and a lack of preoperative transcatheter arterial chemoembolization (TACE) were significant predictors of inferior OS and DFS in multivariate analyses. Conclusions: MIH is an efficient substitute for OH with comparable survival, even in older patients. The reduced LOS and operation time enhance its feasibility, and older patients previously denied for curative resection may qualify for MIH. Preoperative TACE also enhances survival outcomes, emphasizing its general role in managing resectable HCCs. Both robotic and laparoscopic hepatectomies offer acceptable short- and long-term clinical outcomes, highlighting MIH as the standard choice for HCC patients.

This study evaluates whether contrast-enhanced ultrasound (CEUS) serves as an effective next-step imaging modality for patients with end-stage renal disease (ESRD) who have indeterminate renal lesions on computed tomography (CT), assessing its diagnostic performance and potential impact on surgical decision-making. A retrospective chart review was conducted on patients with ESRD who underwent both CEUS and CT between 2021 and 2024 within the VCU Health System. The primary lesion analyzed in each case was the one most concerning for malignancy per the radiology report. If no malignancy was suspected, the largest lesion was selected. Imaging findings from CEUS and CT were assessed based on radiology reports and compared against histopathological results and clinical follow-up. A total of 76 patients met the inclusion criteria. There was no significant difference in lesion characterization accuracy between CEUS and CT ( P =0.51), lesion diameter ( P =0.70), or location ( P =0.87). Among the 12 patients who underwent surgery due to suspected lesion malignancy, 11 (91.7%) were referred for surgery based on CEUS findings, with 100% confirmed malignancy on histopathology. CEUS demonstrates diagnostic performance comparable to CT for characterizing indeterminate renal lesions in patients with ESRD. When used as the next step after noncontrast CT, CEUS can reliably guide surgical decision-making while minimizing contrast and radiation exposure. Early integration of CEUS into structured clinical pathways may streamline evaluation, reduce delays to definitive management, and support timely progression toward transplant eligibility. Its safety, accessibility, and cost-effectiveness make CEUS a valuable tool for guiding care in this complex population.

Acute-on-chronic liver failure (ACLF) is associated with high mortality, yet its distinction from severe alcohol-associated hepatitis (SAH) remains unclear despite overlapping clinical features. We aimed to determine the prevalence of ACLF (by ACLF criteria by the North American Consortium for the Study of End-Stage Liver Disease (NACSELD) among liver transplant (LT) recipients with SAH and compare this with other liver disease etiologies. This short study found that ACLF is common among LT recipients, particularly in those with recent alcohol use, but is not more prevalent in SAH compared to other alcohol-associated liver disease presentations. Current ACLF definitions may underrecognize disease severity in SAH, as most SAH patients demonstrated advanced fibrosis or cirrhosis. Standardized diagnostic criteria integrating ACLF and SAH are needed to better stratify risk and guide transplant evaluation.