Background: Uncontrolled donation after circulatory death (uDCD) remains underutilized globally, despite critical organ shortages. We report outcomes from Israel’s uDCD kidney transplant program compared with the matched donation after brain death (DBD) recipients. Methods: This retrospective cohort study analyzed all uDCD kidney transplants performed at the Rabin Medical Center between January 2018 and December 2024, compared with DBD transplants during the same period. Propensity score matching (1:3 ratio) was performed using recipient demographics, comorbidities, and donor characteristics. Primary outcomes included delayed graft function (DGF), graft failure, and patient survival. Results: Among 92 kidney transplants, 21 (22.8%) were from uDCD donors. After propensity-matching (21 uDCD, 63 DBD), significant baseline differences persisted: uDCD recipients were younger (47.2 ± 11.8 vs. 57.5 ± 10.9 years, p < 0.001) despite a similar dialysis vintage (7.2 ± 3.2 vs. 7.7 ± 3.7 years, p = 0.569). Warm ischemia time was 58.5 ± 12.3 vs. 3.0 ± 0.0 min (p < 0.001), and cold ischemia time was longer in uDCD (13.7 ± 5.9 vs. 8.4 ± 2.5 h, p < 0.001). DGF occurred in 90.5% of uDCD versus 54.1% of DBD recipients (p = 0.006). Graft failure was markedly higher in uDCD (28.6% vs. 1.6%, p = 0.001), yet mortality was lower (14.3% vs. 27.9%, p = 0.339). After a median follow-up of 60 months (IQR 48–72) for both groups, the death-censored 5 year graft survival rate was 71.4% for uDCD versus 98.4% for DBD (p < 0.001). Conclusions: Despite higher rates of DGF and graft failure, uDCD kidney transplantation demonstrated an acceptable 5 year patient survival rate in carefully selected younger recipients. These findings support cautious expansion of uDCD programs with rigorous recipient selection criteria and realistic outcome expectations.

Background/Objectives: Pediatric spontaneous or non-traumatic extrahepatic bile duct perforation (SBDP) is a rare cause of bile ascites and biliary peritonitis. We aimed to characterize presentation, diagnosis, management, outcomes, and summarize practical management considerations. Methods: A systematic review was performed in accordance with PRISMA 2020, we searched PubMed/MEDLINE, EMBASE, and Google Scholar from inception to February 2026, and completed backward citation tracking in June 2026. We included pediatric SBDP cases and excluded traumatic, iatrogenic, isolated gallbladder, and perforated choledochal cyst cases. Case-level data were extracted when available, and exploratory subgroup analyses were performed by age and management approach. Results: A total of 139 studies reported 208 cases; with one institutional case, final cohort of 209 patients. Median age was 3.0 months (IQR, 1.15–15.0; n = 174), and 70.5% of patients were ≤1 year old (124/176). Bilious ascites or bile-stained fluid was confirmed in 95.2%. The cystic duct–CHD/CBD junction was the most frequently reported site (82/180, 45.5%), and biliary anomalies were reported in 39.7% (83/209). A step-up initial management was used in 60.3% and immediate surgery in 38.8%. Reported survival was 97.0% (197/203), although publication bias limits interpretation. Clinical complications and reinterventions were reported in 75/198 (37.9%) and 66/209 (31.6%), respectively. Conclusions: Pediatric SBDP is age-dependent and anatomy-driven; infants more often presented with cholestatic-ascitic features, whereas older children more often had acute-abdominal features. Bilious ascites is an important diagnostic clue. Management should prioritize stabilization and source control, followed by anatomical definition and selective reconstruction.

Background: Kartagener syndrome (KS) is a rare subset of primary ciliary dyskinesia characterized by the triad of situs viscerum inversus (SVI), chronic sinusitis, and bronchiectasis. Laparoscopic cholecystectomy (LC) in patients with SVI is technically demanding because of mirror-image anatomy, while evidence supporting the use of indocyanine green (ICG) fluorescence in this setting is scarce. Case Presentation: We report the case of a 25-year-old woman with KS and SVI totalis who underwent elective LC for symptomatic cholelithiasis. The procedure was performed using a mirror American approach with four trocars and near-infrared ICG fluorescence cholangiography. ICG enabled real-time visualization of biliary anatomy and facilitated intraoperative orientation. The procedure was completed laparoscopically without intraoperative or postoperative complications, and the postoperative course was uneventful. Methods: A non-systematic narrative review of the literature was conducted to identify reported cases of LC in patients with SVI, including cases associated with KS. Studies published between 1991 and 2025 were retrieved from PubMed, Web of Science, Scopus, and Embase. Data were descriptively summarized, focusing on surgical technique, trocar placement, and reported use of ICG fluorescence. Results: A total of 143 articles were included. Most cases involved isolated SVI, while KS was reported only in a minority of patients. The mirror American technique and four-trocar configuration were the most frequently adopted approaches. Only three cases, including the present report, described the use of ICG fluorescence during LC in patients with SVI or KS. Conclusions: LC in patients with SVI is feasible but technically demanding. ICG fluorescence may assist intraoperative biliary orientation in complex anatomical settings; however, current evidence is extremely limited and should be considered hypothesis-generating only.

Background: Laparoscopic living donor nephrectomy is a standard approach for kidney procurement, yet optimal technique and learning curve trajectories remain incompletely characterized. We present a high-volume single-center experience with standardized transperitoneal laparoscopic donor nephrectomy and CUSUM-based learning curve analysis. Methods: Retrospective analysis of 1446 consecutive laparoscopic living donor nephrectomies performed by six surgeons between January 2015 and December 2024. Learning curve analysis used the cumulative sum (CUSUM) methodology to identify proficiency phases. The most recent 200 consecutive cases, representing mature institutional performance, were analyzed for detailed outcomes. The surgical technique employed a transperitoneal approach with the GelPOINT^® Advanced Access Platform for kidney extraction via an offset Pfannenstiel incision. Results: CUSUM analysis identified case 669 as the inflection point, defining four phases: Phase I (initial learning, cases 1–250, n = 250, 154.6 ± 35.9 min), Phase II (rapid improvement, cases 251–669, n = 419, 136.7 ± 32.6 min), Phase III (consolidation, cases 670–1000, n = 331, 118.0 ± 30.1 min), and Phase IV (mastery, cases 1001–1446, n = 446, 101.5 ± 26.2 min). Overall operative time decreased from 154.6 to 96.8 min (37.4% reduction, p < 0.001). In the 200-case mastery-phase cohort, mean operative time was 96.8 ± 25.5 min with warm ischemia time of 3.8 ± 1.2 min. There were no conversions to open surgery (0%), no intraoperative complications, and one major postoperative complication (0.5%, Clavien–Dindo ≥ IIIa). Left kidney procurement was performed in 99.5% of cases. Among male donors (n = 86), systematic orchalgia surveillance demonstrated 46.5% prevalence at 1 month, declining to 36.0% at 1 year, and 7.0% at a 5-year follow-up. Conclusions: This high-volume single-center experience demonstrates favorable outcomes in laparoscopic living donor nephrectomy with CUSUM-defined proficiency phases extending beyond 1000 cases. The outcomes observed likely reflect the combined effects of institutional volume, team experience, and standardized technique. Multi-center validation is required before generalizing these results.

Background: Bile leaks complicate 5–25% of liver transplants and are among the most common early postoperative biliary events. Their management within the first 14 postoperative days has traditionally been framed around the timing of intervention. Objective: To evaluate whether leak characteristics and patient stability provide more consistent guidance than intervention timing for early post-transplant bile leaks. Methods: A structured narrative review using a dual-source search (AI-assisted semantic search [Elicit Plus] and PubMed/MEDLINE) was conducted. A PICO-informed (Population, Intervention, Comparator, Outcome) framework guided inclusion; two independent reviewers preformed screening, with senior adjudication, yielding 37 sources. Because “early” was defined heterogeneously—by leak onset in most studies (definitions exceeding 14 days) and by intervention timing in others—and no study compared timing within a 14-day window, quantitative pooling was not undertaken. Results: No included study directly compared intervention timing within the first 14 postoperative days. In the largest available analysis of ERCP timing, resolution and adverse event rates did not differ by whether endoscopy was performed within one day, on days two to three, or after three days; endoscopic success was consistently high (80–98%) across temporal windows. Leak type was a consistent correlate of management intensity and resolution: anastomotic leaks were associated with higher surgical-intervention rates (40% vs. 8.3% for T-tube exit-site leaks in one cohort) and lower resolution rates (58–69%) than non-anastomotic leaks (90–100%). Within endoscopic therapy, bridging stent placement—not leak location—was the strongest independent predictor of resolution, and any bile leak, irrespective of subtype, independently predicted subsequent biliary stricture (pooled adjusted OR ≈ 4). Ultra-early leaks (≤72 h), frequently technical failures, formed the one subset favoring early surgical re-exploration. Conclusions: The absence of a demonstrated timing effect reflects a lack of direct comparative data rather than proof that timing is unimportant. Leak type, patient stability, and management modality offer more consistent and actionable guidance than temporal urgency, forming the basis for a leak-stratified framework. Prospective multicenter registries with standardized timing strata and leak type stratification are needed to test whether timing independently influences outcomes.

Background/Objectives: Obesity can delay kidney-transplant listing, and metabolic and bariatric surgery (MBS) may help address this barrier, but its role, timing, and procedure choice are not established for every candidate. We evaluated transplant-access outcomes, failed pathways, bariatric safety, procedure-specific considerations, and evidence relevant to pretransplant referral. Methods: PubMed/MEDLINE, Embase, and Google Scholar were searched through 6 August 2026. The review and protocol were prospectively registered in PROSPERO. Reports were mapped to access/pathway, bariatric-safety, post-transplant, and procedure/timing/pharmacokinetic/enteric-oxalate domains. Cumulative transplantation proportions were synthesized as an exploratory outcome using a restricted maximum likelihood random-effects model with Hartung–Knapp confidence intervals. Results: Forty-seven reports from 30 source clusters were included. Across 10 independent bridge cohorts (180/531 transplants), the pooled proportion over heterogeneous study-specific follow-up was 39.6% (95% CI, 28.2–52.3%; I² = 77.4%), with a 95% prediction interval of 12.9–74.4%. This pooled estimate was descriptive and non-comparative. Adjusted observational estimates favored MBS for waitlisting, active listing, or kidney transplantation but were not pooled because their estimands and pathway structures differed. The two randomized trials had some concerns and high risk of bias, respectively, and all 23 nonrandomized comparative results were at serious or critical risk of bias. No validated treatment-effect modifier or referral prediction model was identified. Conclusions: MBS may facilitate transplant access when obesity is a principal reversible barrier. However, very-low-certainty evidence establishes neither a causal effect of MBS on transplant access nor referral criteria, an individual transplantation probability, optimal timing, or superiority of sleeve gastrectomy over gastric bypass. Referral and procedure choice should remain individualized and multidisciplinary.