Objective: To test the hypothesis that comparably injured women, especially those in the hormonally active age groups, would manifest a better preserved hemodynamic response and tissue perfusion after major trauma than do men. Summary Background Data: The notion that premenopausal women are more resistant than men to shock and trauma has been shown in numerous preclinical models. However, human studies on the effects of gender on outcome after shock-trauma are less clear, and none has examined the effect of gender on the immediate postinjury response to major trauma. Methods: Prospective series of all patients at a Level I trauma center from January 2000 to December 2005. Study patients were all patients arriving to the trauma area of the emergency department and having a serum lactate drawn within 30 minutes of arrival. Demographic data, injury severity indices, blood utilization, and lactate levels were recorded. Lactate was used as a marker of the hemodynamic response to injury, because it has been shown to be an excellent and accurate indicator of inadequate tissue perfusion. Results: A total of 5192 patients were eligible for the study of which 4106 fulfilled the study requirements and were enrolled. Initial serum lactate levels were significantly lower in premenopausal (age 14 -44) and perimenopausal (age 45-54) women than in men of the same age groups (P Ͻ 0.001), even though the Injury Severity Score of the women was significantly higher than that of the men (24 vs. 18; P Ͻ 0.1). When patients were stratified into major injury groups as well as groups receiving blood transfusions, the premenopausal women were also found to have lower initial serum lactate levels and receive less blood, while having a greater magnitude of injury as reflected in their Injury Severity Score. Conclusion:The data firmly establishes a proof of principle that hormonally active human women have a better physiologic response to similar degrees of shock and trauma than do their male counterparts. These gender-based differences should be taken into account in designing studies evaluating the response to shock-trauma. (Ann Surg 2007;246: 447-455)

Outcomes of recipients of ML grafts are comparable to SL transplants. Despite liberal use of these grafts, we have been able to successfully reduce waitlist mortality while exceeding national post-transplant survival metrics.

Prerecovery liver biopsy (PLB) can potentially to decrease futile recovery and increase utilization of marginal brain-dead donor (BDD) livers. A case-control study was conducted to examine the logistics, safety, histological precision, and liver utilization associated with PLB in BDDs. Twenty-three cases between January 2008 and January 2013 were compared to 2 groups: 48 sequential and 69 clinically matched controls. Compared to the sequential controls, the cases were older (53 versus 46 years), heavier (30.2 versus 25.8 kg/m 2 ), had higher prevalences of hypertension (78.3% versus 44.7%) and alcohol use (56.5% versus 23.4%), and a lower United Network for Organ Sharing expected organ yield (0.73 versus 0.81 livers/donor; P < 0.05 for all). Baseline characteristics were similar between cases and clinical controls. Donor management time was longer for the cases (22.4 hours) versus sequential controls (16.5 hours, P 5 0.01) and clinical controls (15.9 hours, P 5 0.01). Complications for cases (8.7%) were not different from either group of controls (18.8% for sequential controls, P 5 0.46; 17.4% for clinical controls, P 5 0.50). The agreement between the donor hospital and study pathologists was substantial regarding evaluation of steatosis (j 5 0.623) and fibrosis (j 5 0.627) and moderate regarding inflammation (j 5 0.495). The proportions of livers that were transplanted were similar for the cases and the clinical controls (60.9% versus 59.4%). In contrast, the proportion of donors for whom liver recovery was not attempted was higher (30.4% versus 8.7%), and the proportion of attempted liver recoveries that did not result in transplantation was lower (8.7% versus 31.9%). These differences were significant at P 5 0.009. Overall, PLB is logistically feasible with only a minimal delay and is safe, its interpretation at donor hospitals is reproducible, and it appears to decrease futile liver recovery. Liver Transpl 20:237-244, 2014. V C 2013 AASLD.Received July 5, 2013; accepted October 27, 2013.With the continued scarcity of livers, the transplantation of marginal livers from brain-dead donors (BDDs) and livers from cardiac death donors has increased. Concurrently, the proportion of unused livers has increased during the past decade. Data from the Scientific Registry of Transplant Recipients show that 21% of available livers were not used in 2010, whereas 15% were not used in 2004. 1 Although no uniform definition of a marginal liver BDD exists, typically older donors (age > 60 years), very obese donors, donors with positive hepatitis serologies or other highrisk behaviors, and donors with intracranial malignancies are considered marginal. 2-4 Usually, when a liver is not considered optimal on the basis of clinical, Abbreviations: BDD, brain-dead donor; DHP, donor hospital pathologist; EtOH, ethanol; O/E, observed yield per expected yield; O-E/100, observed yield minus expected yield per 100 donors; OPO, organ procurement organization; PLB, prerecovery liver biopsy; SP, study pathologist; UNOS,

The safety and liver utilization with prerecovery liver biopsy (PLB) in extended criteria liver donors are unclear. We conducted a retrospective cohort study in 1323 brain death donors (PLB = 496) from 3 organ procurement organizations (OPOs). Outcomes were complications, preempted liver recovery (PLR), and liver transplantation (LT). Additional analyses included liver-only and propensity score-matched multiorgan donor subgroups. PLB donors were older (57 versus 53 years; P < 0.001). Hepatitis C antibody positivity (14.3% versus 9.6%, P = 0.01) and liver-only donors (42.6% versus 17.5%; P < 0.001) were more prevalent. The PLB cohort had fewer complications (31.9% versus 42.3%; P < 0.001). In the PLB cohort, PLR was significantly higher (odds ratio [OR], 3.45; 95% confidence interval [CI], 2.42-4.92) and LT lower (OR, 0.69; 95% CI, 0.52-0.91). In liver-only and propensity score-matched multiorgan donor subgroups, PLR was significantly higher (OR, 1.76; 95% CI, 1.06-2.94 and OR, 2.29; 95% CI, 1.37-3.82, respectively) without a decrease in LT (OR, 0.71; 95% CI, 0.43-1.18 and OR, 0.91; 95% CI, 0.63-1.33, respectively) in PLB subgroups. In conclusion, in extended criteria liver donors, PLB is safe and decreases futile liver recovery without decreasing LT. Increased use of PLB, especially in liver-only donors, is likely to save costs to OPOs and transplant centers and improve efficiencies in organ allocation. Liver Transplantation 24 182-191 2018 AASLD.

Biliary complications are a common cause of morbidity after liver transplantation, with biliary stone formation being a known occurrence generally upstream of a stricture. A 12-year-old boy, who underwent an orthotopic liver transplantation at 11 months of age for biliary atresia, presented acutely with fever and abdominal pain. Cross-sectional imaging revealed Roux-en-Y limb dilatation and thickening. He was explored and was found to have an ischemic Roux limb secondary to an obstructing enterolith. A segmental bowel resection and revision of his hepaticojejunostomy was performed. While rare, biliary enteroliths may present as either a bowel obstruction or cholangitis and should be considered in the differential diagnosis of a patient following biliary reconstruction. Additionally, anatomic etiologies should be considered and potentially surgically corrected.

Considerable variability exists in the use of PLB. Additional information on the utility, accuracy, and safety of PLB are needed to optimize its use.

No abstract

Pancreas transplantation venous effluent can be drained via the portal vein or the systemic circulation; however, no recommendation exists for the ideal technique. A systematic review of the literature from 1989 through 2014 using PubMed, CINHAL, and Cochrane Library for portal versus systemic venous drainage was undertaken. Only studies on humans and published in English were considered. Measures of glycemic control and total cholesterol were synthesized for meta-analysis utilizing random-effects models. Of 166 articles retrieved, 15 articles were included for meta-analysis. Patient and graft survival were comparable in a large database study as well as in the only randomized control study. No differences in complications were seen when exocrine drainage was enteric for the systemic venous group. Fasting insulin (-34.13 pmol/mL, p < 0.001) was significantly lower within the portal drained group; however, fasting blood glucose levels (-3.4 mg/dL, p = 0.32) and hemoglobin A1C levels (mean difference 0.124%, p = 0.25) were comparable. Total cholesterol levels (-3.62 mg/dL, p = 0.447), as well as other measures of lipids, showed no difference. Based on this systematic review and meta-analysis, there is no evidence of differences in outcomes or metabolic control in patients undergoing pancreatic transplant with portal venous drainage compared to the systemic venous drainage.