Medical assistance in dying (MAiD) has been a legally approved practice in Canada since 2016. Only recently have patients undergoing MAiD also been considered as donors for liver transplantation (LT). This study aimed to evaluate a case series of LT outcomes for recipients with MAiD donors and was paired with a systematic literature review of studies assessing the efficacy of MAiD-associated liver donation. A retrospective chart review of patients registered within the LT Registry at London Health Sciences Centre (LHSC) in London, Ontario, Canada, that had received MAiD donor LT was conducted to develop a case series. Descriptive statistics were produced based on available patient outcomes information. The systematic review included euthanasia due to MAiD being a term exclusive to Canada. Case series had a 100% 1-year graft survival rate, with 50% of patients experiencing early allograft dysfunction but having no significant clinical outcome. A single case of postoperative biliary complication was reported. Median warm ischemic time ranged from 7.8–13 minutes among case series and literature reviews. Utilization of donation after circulatory death allografts procured after MAiD appears to be promising. Mechanisms associated with potential impact in postoperative outcomes include relatively lower warm ischemic time relative to donation after circulatory death Maastricht III graft recipients.

While patients with borderline resectable pancreatic cancer (BRPC) are a target population for neoadjuvant chemotherapy (NAC), formal guidelines for neoadjuvant therapy are lacking. We assessed the perioperative and oncological outcomes in patients with BRPC undergoing NAC with FOLFIRINOX for patients undergoing upfront surgery (US). The AHPBA criteria for borderline resectability and/or a CA19-9 level > 100 μ/mL defined borderline resectable tumors retrieved from a prospectively populated institutional registry from 2007 to 2020. The primary outcome was overall survival (OS) at 1 and 3 years. A Cox Proportional Hazard model based on intention to treat was used. A receiver-operator characteristics (ROC) curve was constructed to assess the discriminatory capability of the use of CA19-9 > 100 μ/mL to predict resectability and mortality. Forty BRPC patients underwent NAC, while 46 underwent US. The median OS with NAC was 19.8 months (interquartile range [IQR], 10.3-44.24) vs. 10.6 months (IQR, 6.37-17.6) with US. At 1 year, 70% of the NAC group and 41.3% of the US group survived (p = 0.008). At 3 years, 42.5 % of the NAC group and 10.9% of the US group survived (p = 0.001). NAC significantly reduced the hazard of death (adjusted hazard ratio, 0.20; 95% confidence interval, 0.07-0.54; p = 0.001). CA19-9 > 100 μ/mL showed poor discrimination in predicting mortality, but was a moderate predictor of resectability. We found a survival benefit of NAC with FOLFIRINOX for BRPC. Greater pre-treatment of CA19-9 and multivessel involvement on initial imaging were associated with progression of the disease following NAC.

Gautham Nair, Ali Hadi, Kartik Gupta, Edward Tran, Geerthan Srikantharajah, Evelyn Waugh, Ephraim Tang, Anton Skaro, Juan Glinka. Ann Hepatobiliary Pancreat Surg -0001;0:. https://doi.org/10.14701/ahbps.25-046

The benefits of MIS in older adults are conflicting. This study evaluates demographics and early outcomes, for older patients (≥75) undergoing minimally invasive (MIS) versus open pancreaticoduodenectomy (PD). We categorized elderly patients who underwent PD from 2017 to 2021 NSQIP databases by surgical approach (open vs MIS). Baseline characteristics were examined with bivariate analysis, and multivariate logistic regression assessed the independent effect of minimally invasive surgery on 30-day serious complications and mortality. Amongst 4137 patients, 150 (3.63 %) underwent MIS PD. Patients demographics were similar. Open cohorts were older (79.1 vs 78.4 years; p = 0.011) with greater tumor invasion (36.6 % vs. 27.0 %; p = 0.018). MIS had longer operations (133.1 vs 119.6 min; p < 0.001). Multivariate analysis demonstrated that MIS approach was associated with increased serious complications (OR 2.21; p < 0.001), but not mortality (OR 2.11; p = 0.173). Post hoc analysis excluding cases converted to open demonstrated no difference in serious complications (OR 1.94; p = 0.070) or mortality (OR 3.58; p = 0.094). PSM analysis estimated a 14.7 % higher rate of serious complications in MIS but similar mortality (p = 0.291). MIS PD uptake in elderly patients remains limited, with early findings indicating longer operations and higher complications. Further research on patient selection differences, technique modifications, and center expertise is required.

Background: Benign biliary strictures can have a significant negative impact on patient quality of life. There are several modalities which can be utilized with the goal of stricture resolution. These techniques include balloon dilatation, placement of multiple plastic stents and more recently, the use of metal stents. The aim of this study was to evaluate the local success of self-expanding metal stents in successfully resolving benign biliary strictures. Methods: This was a single institution, retrospective case series. Patients included in our study were patients who underwent endoscopic retrograde cholangiopancreatography with placement of self expanding metal stents for benign biliary strictures at our institution between 2016–2022. Patients were excluded for the following: malignant stricture, and inability to successfully place metal stent. Data was evaluated using two-sided t-test with 95% confidence interval. Results: A total of 31 patients underwent placement of 43 self-expanding metal stents and met inclusion criteria. Mean age of patients was 59 ± 10 years, and were largely male (74.2% vs. 25.8%). Most strictures were anastomotic stricture post liver transplant (87.1%), while the remainder were secondary to chronic pancreatitis (12.9%). Complications of stent placement included cholangitis (18.6%), pancreatitis (2.3%), stent migration (20.9%), and inability to retrieve stent (4.7%). There was successful stricture resolution in 73.5% of patients with anastomotic stricture and 33.3% of patients with stricture secondary to pancreatitis. Resolution was more likely if stent duration was > / = 180 days (73.3% vs. 44.4%, p < 0.05). There was no demonstrated added benefit when stent duration was > / = 365 days (75% vs. 60.9%, p = 0.64). Conclusions: This study demonstrates that self expanding metal stents are a safe and effective treatment for benign biliary strictures, with outcomes comparable to plastic stents with fewer interventions. This study indicates that the optimal duration to allow for stricture resolution is 180–365 days.

INTRODUCTION: Decompensated cirrhosis has a median survival of 2 years without liver transplantation (LT). This study investigates whether distance from LT center affects waitlist mortality and receipt of LT. METHODS: The study population was generated from the transplant database in London, Ontario, Canada. Adult patients on the waitlist for LT between January 1, 2012, and December 31, 2021, were included. Data were linked to the Institute for Clinical Evaluative Sciences to examine clinically relevant outcomes, using ≤150 km vs >150 km to stratify descriptive analysis. Multivariate time-to-event analyses were conducted to evaluate the hazards of increasing distance from LT center on waitlist mortality and receipt of LT. RESULTS: Of the 552 patients meeting study criteria, 394 (71.4%) received LT in an overall predominantly male cohort (n = 390, 70%), with a median age of 59 years (interquartile range [IQR] 52–64) and median distance from the LT center of 110 km (IQR 59–191). There were no significant differences between patients living ≤150 km (n = 362) vs >150 km (n = 190) from the LT center. In liver disease etiology—alcohol-related liver disease remained the most common (32.9% vs 33.2%; P = 0.95) across both categories, with no difference in median Model for End Stage Liver Disease-Sodium scores between those who did and did not receive transplant (17 [IQR 9–25] vs 18 [IQR 10–27]; P = 0.12). On multivariable analysis, distance to the LT center did not affect receipt of LT, waitlist mortality, or postlisting ED visits and hospitalizations. Model for End-Stage Liver Disease-Sodium at listing was a significant predictor of increased waitlist mortality (hazard ratio 1.12; confidence interval 1.09–1.16; P < 0.01), whereas hepatocellular carcinoma diagnosis was associated with reduced waitlist mortality (hazard ratio 0.13; confidence interval 0.04–0.45; P < 0.01). Patients further from the LT center had a higher median number of hospitalizations (2 vs 1; P = 0.02) and emergency department (ED) visits (3 vs 2; P < 0.01) in the year before LT listing, and significantly ED utilization within 90 days postlisting (0 [IQR 0–2] vs 0 [IQR 0–1]; P < 0.05), albeit this was not consistent on multivariable analysis. DISCUSSION: Geographical distance does not significantly affect LT waitlist mortality or receipt of LT. However, differences in healthcare utilization suggest disparities may still manifest with a negative impact on patients in the pre-LT setting.