Background and Aims: In liver transplantation, cold preservation induces ischemia, resulting in significant reperfusion injury. Hypothermic oxygenated machine perfusion (HMP-O₂) has shown benefits compared to static cold storage (SCS) by limiting ischemia-reperfusion injury. This study reports outcomes using a novel portable HMP-O₂ device in the first US randomized control trial. Approach and Results: The PILOT trial (NCT03484455) was a multicenter, randomized, open-label, noninferiority trial, with participants randomized to HMP-O₂ or SCS. HMP-O₂ livers were preserved using the Lifeport Liver Transporter and Vasosol perfusion solution. The primary outcome was early allograft dysfunction. Noninferiority margin was 7.5%. From April 3, 2019, to July 12, 2022, 179 patients were randomized to HMP-O₂ (n=90) or SCS (n=89). The per-protocol cohort included 63 HMP-O₂ and 73 SCS. Early allograft dysfunction occurred in 11.1% HMP-O₂ (N=7) and 16.4% SCS (N=12). The risk difference between HMP-O₂ and SCS was −5.33% (one-sided 95% upper confidence limit of 5.81%), establishing noninferiority. The risk of graft failure as predicted by Liver Graft Assessment Following Transplant score at seven days (L-GrAFT₇) was lower with HMP-O₂ [median (IQR) 3.4% (2.4–6.5) vs. 4.5% (2.9–9.4), p=0.024]. Primary nonfunction occurred in 2.2% of all SCS (n=3, p=0.10). Biliary strictures occurred in 16.4% SCS (n=12) and 6.3% (n=4) HMP-O₂ (p=0.18). Nonanastomotic biliary strictures occurred only in SCS (n=4). Conclusions: HMP-O₂ demonstrates safety and noninferior efficacy for liver graft preservation in comparison to SCS. Early allograft failure by L-GrAFT₇ was lower in HMP-O₂, suggesting improved early clinical function. Recipients of HMP-O₂ livers also demonstrated a lower incidence of primary nonfunction and biliary strictures, although this difference did not reach significance.

Morbid obesity is a barrier to kidney transplantation (KT) in patients with end‐stage renal disease (ESRD). Laparoscopic sleeve gastrectomy (SG) is an increasingly considered intervention, but the safety and long‐term outcomes are uncertain. We reviewed prospectively collected data on patients with ESRD and chronic kidney disease (CKD) undergoing SG from 2011 to 2018. 198 patients with ESRD and 45 patients with CKD (stages 1‐4) met NIH guidelines for bariatric surgery and underwent SG. 72% and 48% achieved a BMI ≤40 and ≤35, respectively. The mean percentages of total weight loss and excess weight loss were 18.9±10.8% and 38.2±20.3%, respectively. SG reduced hypertension (HTN) (85.8% vs. 52.1%), decreased anti‐hypertensive medications (1.6 vs. 1.0) (p<0.01 each), and reduced diabetes (59.6% vs. 32.5%, p<0.01). 45 of the 71 patients with ESRD that achieved a BMI ≤40 were waitlisted and received KT, while ten remain on the waitlist. Mortality rate after SG was 1.8 per 100 patient‐years, compared to 7.3 for non‐SG. Patients with stage 3a or 3b CKD exhibited improved GFR (43.5 vs. 58.4 ml/min, p=0.01). In conclusion, SG safely improves transplant candidacy while providing significant, sustainable effects on weight loss, reducing medical comorbidities and possibly improving renal function in Stage 3 patients.

Burnout among surgeons has been attributed to increased workload and decreased autonomy. Although prior studies have examined burnout among transplant surgeons, no studies have evaluated burnout in abdominal transplant surgery fellows. The objective of our study was to identify predictors of burnout and understand its impact on personal and patient care during fellowship. A survey was sent to all abdominal transplant surgery fellows in an American Society of Transplant Surgeons‐accredited fellowship. The response rate was 59.2% (n=77) and 22.7% (n=17) of fellows met criteria for burnout. Fellows with lower grit scores were more likely to exhibit burnout compared to fellows with higher scores (3.6 vs 4.0, p=0.026). Those with burnout were more likely to work over 100 hours per week (58.8% vs 27.6%, p=0.023), have severe work‐related stress (58.8% vs 22.4%, p=0.010), consider quitting fellowship (94.1% vs 20.7%, p<0.001), or make a medical error (35.3% vs 5.2%, p=0.003). This national analysis of abdominal transplant fellows found that burnout rates are relatively low, but few fellows engage in self‐care. Personal and program‐related factors attribute to burnout and it has unacceptable effects on patient care. Transplant societies and fellowship programs should develop interventions to give fellows tools to prevent and combat burnout.

BACKGROUND: Transplant surgery fellowship has evolved over the years and today there are 66 accredited training programs in the US and Canada. There is growing concern, however, about the number of US-trained general surgery residents pursuing transplant surgery. In this study, we examined the transplant surgery pipeline, comparing it with other surgical subspecialty fellowships, and characterized the resident transplantation experience. METHODS: Datasets were compiled and analyzed from surgical fellowship match data obtained from the National Resident Matching Program and ACGME reports and relative fellowship competitiveness was assessed. The surgical resident training experience in transplantation was evaluated. RESULTS: From 2006 to 2018, a total of 1,094 applicants have applied for 946 transplant surgery fellowship positions; 299 (27.3%) were US graduates. During this period, there was a 0.8% decrease per year in US-trained surgical residents matching into transplant surgery (p = 0.042). In addition, transplant surgery was one of the least competitive fellowships compared with other National Resident Matching Program surgical subspeciality fellowships, as measured by the number of US applicants per available fellowship position, average number of fellowship programs listed on each applicant's rank list, and proportion of unfilled fellowship positions (each, p < 0.05). Finally, from 2015 to 2017, there were 57 general surgery residency programs that produced 77 transplant surgery fellows, but nearly one-half of the fellows (n = 36 [46.8%]) came from 16 (28.1%) programs. CONCLUSIONS: Transplant surgery is one of the least competitive and sought after surgical fellowships for US-trained residents. These findings highlight the need for dedicated efforts to increase exposure, mentorship, and interest in transplantation to recruit strong US graduates.