Quality and efficacy of Multidisciplinary Team (MDT) quality assessment tools and discussion checklists: a systematic review.

BACKGROUND: MDT discussion is the gold standard for cancer care in the UK. With the incidence of cancer on the rise, demand for MDT discussion is increasing. The need for efficiency, whilst maintaining high standards, is therefore clear. Paper-based MDT quality assessment tools and discussion checklists may represent a practical method of monitoring and improving MDT practice. This reviews aims to describe and appraise these tools, as well as consider their value to quality improvement. METHODS: Medline, EMBASE and PsycInfo were searched using pre-defined terms. The PRISMA model was followed throughout. Studies were included if they described the development of a relevant tool, or if an element of the methodology further informed tool quality assessment. To investigate efficacy, studies using a tool as a method of quality improvement in MDT practice were also included. Study quality was appraised using the COSMIN risk of bias checklist or the Newcastle-Ottawa scale, depending on study type. RESULTS: The search returned 7930 results. 18 studies were included. In total 7 tools were identified. Overall, methodological quality in tool development was adequate to very good for assessed aspects of validity and reliability. Clinician feedback was positive. In one study, the introduction of a discussion checklist improved MDT ability to reach a decision from 82.2 to 92.7%. Improvement was also noted in the quality of information presented and the quality of teamwork. CONCLUSIONS: Several tools for assessment and guidance of MDTs are available. Although limited, current evidence indicates sufficient rigour in their development and their potential for quality improvement. TRIAL REGISTRATION: PROSPERO ID: CRD42021234326 .

Impact of SARS-CoV-2 pandemic on pancreatic cancer services and treatment pathways: United Kingdom experience.

INTRODUCTION: The SARS-CoV-2 pandemic presented healthcare providers with an extreme challenge to provide cancer services. The impact upon the diagnostic and treatment capacity to treat pancreatic cancer is unclear. This study aimed to identify national variation in treatment pathways during the pandemic. METHODS: A survey was distributed to all United Kingdom pancreatic specialist centres, to assess diagnostic, therapeutic and interventional services availability, and alterations in treatment pathways. A repeating methodology enabled assessment over time as the pandemic evolved. RESULTS: Responses were received from all 29 centres. Over the first six weeks of the pandemic, less than a quarter of centres had normal availability of diagnostic pathways and a fifth of centres had no capacity whatsoever to undertake surgery. As the pandemic progressed services have gradually improved though most centres remain constrained to some degree. One third of centres changed their standard resectable pathway from surgery-first to neoadjuvant chemotherapy. Elderly patients, and those with COPD were less likely to be offered treatment during the pandemic. CONCLUSION: The COVID-19 pandemic has affected the capacity of the NHS to provide diagnostic and staging investigations for pancreatic cancer. The impact of revised treatment pathways has yet to be realised.

Surgical Management of Non-Metastatic Pancreatic Cancer in the United Kingdom: Results of a Nationwide Survey on Current Practice.

BACKGROUND: It is presently unclear what clinical pathways are followed for patients with non-metastatic PDAC in specialised centres for pancreatic surgery across the United Kingdom (UK). METHODS: Between August 2019 and August 2020 an electronic survey was conducted aiming at a national cohort of pancreatic surgeons in the UK. Participants replied to a list of standardised questions and clinical vignettes, and data were collected and analysed focusing on management preferences, resectability criteria, and contraindications to surgery. RESULTS: Within the study period, 65 pancreatic surgeons from 27 specialist centres in the UK (96%) completed the survey. Multidisciplinary team meetings are utilised universally for the management of patients with PDAC, however, different staging systems for resectability classification are being applied. In borderline resectable PDAC, most surgeons were keen to proceed with surgical exploration post NAT, but differences were noted in preferred chemotherapy regimens. Surgeons from standard volume institutions performed fewer vein resections annually and were more likely to deem patients with locally advanced PDAC as unresectable. Intra-institutional variability in patient management was also present and ranging between 20-80%. CONCLUSIONS: Significant variability in the surgical management of non-metastatic PDAC was identified both on inter- and intra-institutional level.

Variation in the Use of Resection for Colorectal Cancer Liver Metastases.

OBJECTIVE: The aim of this study was to investigate variation in the frequency of resections for colorectal cancer liver metastases across the English NHS. BACKGROUND: Previous research has shown significant variation in access to liver resection surgery across the English NHS. This study uses more recent data to identify whether inequalities in access to liver resection still persist. METHODS: All adults who underwent a major resection for colorectal cancer in an NHS hospital between 2005 and 2012 were identified in the COloRECTal cancer data Repository (CORECT-R). All episodes of care, occurring within 3 years of the initial bowel operation, corresponding to liver resection were identified. RESULT: During the study period 157,383 patients were identified as undergoing major resection for a colorectal tumor, of whom 7423 (4.7%) underwent ≥1 liver resections. The resection rate increased from 4.1% in 2005, reaching a plateau around 5% by 2012. There was significant variation in the rate of liver resection across hospitals (2.1%-12.2%). Patients with synchronous metastases who have their primary colorectal resection in a hospital with an onsite specialist hepatobiliary team were more likely to receive a liver resection (odds ratio 1.22; 95% confidence interval, 1.10-1.35) than those treated in one without. This effect was absent in resection for metachronous metastases. CONCLUSIONS: This study presents the largest reported population-based analysis of liver resection rates in colorectal cancer patients. Significant variation has been observed in patient and hospital characteristics and the likelihood of patients receiving a liver resection, with the data showing that proximity to a liver resection service is as important a factor as deprivation.

Gender representation in leadership roles in UK surgical societies.

INTRODUCTION: Despite making up more than half of new doctors, women are underrepresented in most surgical specialties. Various reasons have been suggested for this including issues with work-life balance, discrimination and a lack of female role models in the specialty. We sought to quantify the extent of gender discrimination in leadership roles in surgical societies in the UK. METHODS: All major Surgical Specialty Organisations were identified via the Royal College of Surgeons Website. Leadership and committee information was collected via organisation websites on 5th September 2018. All societies were then contacted requesting data including total membership, their stage of training and the gender split. RESULTS: Of the twenty-four organisations contacted, eighteen were able to provide data. Women accounted for 11.8% (2446/20 803) of consultant and 34.3% (5267/15 366) of trainee members. 2/24 presidents; 3/26 of vice presidents; 18.1% (39/215) of executive committees and 13.5% (49/364) of wider committee members were female. Thirty-four committee members were not included as they were not surgeons (23 female; 11 male). DISCUSSION: Despite accounting for 27% of the surgical workforce and indeed 24% of surgical society members, women account for only 2 of 24 Presidents and 18.1% (39/215) of the executive committees of surgical societies in the UK. Action should be taken so women are fairly represented in leadership roles in surgical societies with one of the benefits being more visible role models for prospective female surgeons.

The impact of advancing age on incidence of hepatectomy and post-operative outcomes in patients with colorectal cancer liver metastases: a population-based cohort study.

BACKGROUND: Clinical outcomes for elderly patients undergoing liver resection for colorectal cancer (CRC) liver metastases are poorly characterised. This study aimed to investigate the impact of advancing age on the incidence of liver resection and post-operative outcomes. METHODS: Patients in the National Bowel Cancer Audit undergoing major CRC resection from 2010 to 2016 in England were included. Liver resection was identified from linked Hospital Episode Statistics data. A Cox-proportional hazards model was used to compare 3-year mortality. RESULTS: Of 117,005 patients, 6081 underwent liver resection. For patients <65 years there was 1 liver resection per 12 cases, 65-74, 1 per 17, and ≥75, 1 per 40. 90-day mortality after liver resection increased with advancing age (<65 0.9% (26/2829), 65-74 2.8% (57/2070), ≥75 4.0% (47/1182); P < 0.001). Age was an independent risk factor for 3-year mortality. Patients 65-74 did not have adjusted mortality higher than those <65, yet age ≥75 was associated with increased overall mortality (Hazard ratio (HR) 1.47 (95% CI 1.30-1.68)) and cancer-specific mortality (HR 1.30 (95% CI 1.13-1.49)). CONCLUSION: Although advancing age was associated with higher rates of 90-day mortality following liver resection, 3-year mortality for patients 65-74 years was comparable to younger patients. These results will aid clinicians and patients in pre-operative decision-making.

Radical operation for hilar cholangiocarcinoma in comparable Eastern and Western centers: Outcome analysis and prognostic factors.

BACKGROUND: Extensive resection for hilar cholangiocarcinoma is the most effective treatment, but high morbidity and poor prognosis remain concerns. Previous data have shown marked differences in outcomes between comparable Eastern and Western centers. We compared the outcomes of the management for hilar cholangiocarcinoma at one Japanese and one British institution with comparable experience. METHODS: Of 298 consecutive patients with hilar cholangiocarcinoma evaluated at Hirosaki University Hospital, Japan and St. James's University Hospital, Leeds, UK, 183 underwent radical resection. Clinicopathologic variables and postoperative outcomes were compared. RESULTS: Significant differences were not observed between the Hirosaki and Leeds cohorts in overall outcomes despite several differences in the patient characteristics. Although there was a difference in 90-day mortality (2.5% vs 13.6%, respectively), disease-specific 5-year survival rates were 32.8% and 31.9%, respectively (P = .767). Multivariate analysis identified trisectionectomy (odds ratio = 2.32; P = .010), combined pancreatoduodenectomy (odds ratio = 7.88; P = .010), and perioperative blood transfusion (odds ratio = 1.88; P = .045) were associated with postoperative major complications, while preoperative biliary drainage associated with postoperative major complications, while preoperative biliary drainage (risk ratio = 2.21; P = .018), perioperative blood transfusion (risk ratio = 1.58; P = .029), lymph node metastasis (risk ratio = 2.00; P = .002), moderate/poorly differentiated tumor (risk ratio = 1.72; P = .029), microvascular invasion (risk ratio = 1.63; P = .046), and R1 resection (risk ratio = 1.90; P = .005) were risk factors for poor survival. CONCLUSION: Disease-specific survival and prognostic factors were similar in both centers. Meticulous operative technique to avoid perioperative blood transfusion may improve long-term survival.

Posterior Superior Mesenteric Artery First Dissection Versus Classical Approach in Pancreaticoduodenectomy: Outcomes of a Case-Matched Study.

OBJECTIVES: Posterior superior mesenteric artery (SMA) first dissection in pancreaticoduodenectomy (PD) may allow for early assessment of resectability and aberrant anatomy. Study objectives were to compare resection margins, perioperative outcomes, disease-free survival (DFS) and overall survival (OS) in patients undergoing a posterior SMA first dissection PD to a classical technique PD. METHODS: Patients (n = 77) who underwent a posterior SMA first PD for adenocarcinoma were case matched for patient and tumor characteristics with patients undergoing a classical approach PD from 2006 to 2014 (n = 177). RESULTS: The SMA first patients had an improved negative resection margin rate (27 [35.1%] vs 14 [18.2%], P = 0.042) and a higher lymph node yield (median 28 [22-34] vs 21 [17-27], P < 0.001) compared with the classical approach group. No difference was demonstrated in serious complications or 30-day mortality between the SMA first and classical approach patients (Clavien-Dindo 3/4 16 [20.8%] vs 11 [14.3%], P = 0.336; 30-day mortality 3 [3.9%] vs 3 [3.9%], P = 1.00 respectively). Median DFS and OS was similar in SMA first compared with classical approach patients (DFS, 1.6 vs 1.1 years, P = 0.122; OS, 2.5 vs 1.5 years, P = 0.220 respectively). CONCLUSIONS: A posterior SMA first approach is a comparably safe technique that may improve oncological results in PD compared with classical approach dissection.

The effect of Liver Transplantation on the quality of life of the recipient's main caregiver - a systematic review.

Liver transplantation (LT) is a transformative, life-saving procedure with life-long sequale for patients and their caregivers. The impact of LT on the patient's main caregiver can be underestimated. We carried out a systematic review of the impact of LT on the Health-Related Quality of Life (HRQL) of LT patients' main caregivers. We searched 13 medical databases from 1996 to 2015. We included studies with HRQL data on caregivers of patients following LT then quality assessed and narratively synthesized the findings from these studies. Of 7076 initial hits, only five studies fell within the scope of this study. In general, they showed caregiver burden persisted in the early period following LT. One study showed improvements, however, the other four showed caregiver's levels of stress, anxiety and depression, remained similar or got worse post-LT and remained above that of the normal population. It was suggested that HRQL of the patient impacted on the caregiver and vice versa and may be linked to patient outcomes. No data were available investigating which groups were at particular risk of low HRQL following LT or if any interventions could improve this. The current information about LT caregivers' needs and factors that impact on their HRQL are not adequately defined. Large studies are needed to examine the effects of LT on the patients' family and caregivers to understand the importance of caregiver support to maximize outcomes of LT for the patient and their caregivers.

Calculating the risk of a pancreatic fistula after a pancreaticoduodenectomy: a systematic review.

BACKGROUND: A post-operative pancreatic fistula (POPF) is a major cause of morbidity and mortality after a pancreaticoduodenectomy (PD). This systematic review aimed to identify all scoring systems to predict POPF after a PD, consider their clinical applicability and assess the study quality. METHOD: An electronic search was performed of Medline (1946-2014) and EMBASE (1996-2014) databases. Results were screened according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and quality assessed according to the QUIPS (quality in prognostic studies) tool. RESULTS: Six eligible scoring systems were identified. Five studies used the International Study Group on Pancreatic Fistula (ISGPF) definition. The proposed scores feature between two and five variables and of the 16 total variables, the majority (12) featured in only one score. Three scores could be fully completed pre-operatively whereas 1 score included intra-operative and two studies post-operative variables. Four scores were internally validated and of these, two scores have been subject to subsequent multicentre review. The median QUIPS score was 38 out of 50 (range 16-50). CONCLUSION: These scores show potential in calculating the individualized patient risk of POPF. There is, however, much variation in current scoring systems and further validation in large multicentre cohorts is now needed.

Regional differences in prostaglandin E2 metabolism in human colorectal cancer liver metastases.

BACKGROUND: Prostaglandin (PG) E2 plays a critical role in colorectal cancer (CRC) progression, including epithelial-mesenchymal transition (EMT). Activity of the rate-limiting enzyme for PGE2 catabolism (15-hydroxyprostaglandin dehydrogenase [15-PGDH]) is dependent on availability of NAD+. We tested the hypothesis that there is intra-tumoral variability in PGE2 content, as well as in levels and activity of 15-PGDH, in human CRC liver metastases (CRCLM). To understand possible underlying mechanisms, we investigated the relationship between hypoxia, 15-PGDH and PGE2 in human CRC cells in vitro. METHODS: Tissue from the periphery and centre of 20 human CRCLM was analysed for PGE2 levels, 15-PGDH and cyclooxygenase (COX)-2 expression, 15-PGDH activity, and NAD+/NADH levels. EMT of LIM1863 human CRC cells was induced by transforming growth factor (TGF) ß. RESULTS: PGE2 levels were significantly higher in the centre of CRCLM compared with peripheral tissue (P = 0.04). There were increased levels of 15-PGDH protein in the centre of CRCLM associated with reduced 15-PGDH activity and low NAD+/NADH levels. There was no significant heterogeneity in COX-2 protein expression. NAD+ availability controlled 15-PGDH activity in human CRC cells in vitro. Hypoxia induced 15-PGDH expression in human CRC cells and promoted EMT, in a similar manner to PGE2. Combined 15-PGDH expression and loss of membranous E-cadherin (EMT biomarker) were present in the centre of human CRCLM in vivo. CONCLUSIONS: There is significant intra-tumoral heterogeneity in PGE2 content, 15-PGDH activity and NAD+ availability in human CRCLM. Tumour micro-environment (including hypoxia)-driven differences in PGE2 metabolism should be targeted for novel treatment of advanced CRC.

Implantable versus cuffed external central venous catheters for the management of children and adolescents with acute lymphoblastic leukaemia.

PURPOSE: The aim of this study was to determine if there is a difference between complications for totally implantable central venous catheters (ports) and tunnelled external central venous catheters (external CVCs) that result in early removal of the central venous catheter (CVC) in children and adolescents with acute lymphoblastic leukaemia (ALL). METHODS: All children hospitalised between November 1996 and December 2007 with ALL who had a CVC were included retrospectively. We analysed data regarding the patient's first CVC. RESULTS: We included 322 patients. 254 received a port and 68 received an external CVC. There were 102 CVC complications that required removal of the CVC prior to the completion of chemotherapy (65 in patients with ports, 37 in patients with external CVCs). Overall complications requiring CVC removal were significantly less likely to occur in the patient's with ports (p < 0.001). Ports were significantly less likely to require removal prior to the end of treatment overall (p < 0.001) and for specific complications such as infection (p < 0.001) and dislodgement (p = 0.001). However, when adjusted for disease severity there is no difference in premature CVC removal rates. CONCLUSION: When patients are risk-stratified for disease severity there is no difference in rates of CVC removal prior to completion of treatment.

Role of quantification of hepatic steatosis and future remnant volume in predicting hepatic dysfunction and complications after liver resection for colorectal metastases: a pilot study.

OBJECTIVES: Accurate prediction of safe remnant liver volume to minimize complications following liver resection remains challenging. The aim of this study was to assess whether quantification of steatosis improved the predictive value of preoperative volumetric analysis. METHODS: Thirty patients undergoing planned right or extended right hemi-hepatectomy for colorectal metastases were recruited prospectively. Magnetic resonance imaging was used to assess the level of hepatic steatosis and future remnant liver volume. These data were correlated with data on postoperative hepatic insufficiency, complications and hospital stay. Correlations of remnant percentage, remnant mass to patient mass and remnant mass to body surface area with and without steatosis measurements were assessed. RESULTS: In 10 of the 30 patients the planned liver resection was altered. Moderate-severe postoperative hepatic dysfunction was seen in 17 patients. Complications arose in 14 patients. The median level of steatosis was 3.8% (range: 1.2-17.6%), but was higher in patients (n= 10) who received preoperative chemotherapy (P= 0.124), in whom the median level was 4.8% (range: 1.5-17.6%). The strongest correlation was that of remnant liver mass to patient mass (r= 0.77, P < 0.001). However, the addition of steatosis quantification did not improve this correlation (r= 0.76, P < 0.001). CONCLUSIONS: This is the first study to combine volumetric with steatosis quantifications. No significant benefit was seen in this small pilot. However, these techniques may be useful in operative planning, particularly in patients receiving preoperative chemotherapy.

Hepatocellular carcinoma within a noncirrhotic, nonfibrotic, seronegative liver: surgical approaches and outcomes.

BACKGROUND: Hepatocellular carcinoma (HCC) most commonly arises in patients with chronic liver disease. Data on outcomes after liver resection in patients with noncirrhotic, nonfibrotic, seronegative, referred to as a "normal" liver are limited. We aimed to investigate differences in prognostic factors and outcomes between patients presenting with HCC arising in "normal" liver (NLHCC) and that arising in "diseased" liver (DLHCC). STUDY DESIGN: All patients undergoing resection for HCC between 1994 and 2008 were assessed. Multivariable analysis of clincopathologic data from the NLHCC group was performed by comparing them with data from the group who had surgery for DLHCC during this period. RESULTS: During the 15-year study period, 142 patients underwent liver resection for HCC: 81 for NLHCC and 61 for DLHCC. NLHCCs were more often solitary but were larger and required more major resections. There was no significant difference in survival outcomes between patients who had NLHCC or DLHCC, with overall and recurrence-free 5-year survivals of 60% and 51% in NLHCC and 55% and 33% in DLHCC, respectively. In patients with NLHCC, significant factors predicting overall survival were blood transfusion requirement (p = 0.003) and age (p = 0.009), and the only significant factor at predicting recurrence-free survival was presence of multiple tumors (p = 0.025). In contrast, in DLHCC, the only significant prognostic variables were a preoperative tumor biopsy (p = 0.017) or a high neutrophil-to-lymphocyte ratio (p = 0.001), both of which predicted a poorer recurrence-free survival. CONCLUSIONS: HCC presenting in patients with a normal background liver parenchyma appears to present a different spectrum of the disease. However, excellent outcomes can be achieved after liver resection, although this often requires the use of advanced techniques due to late presentation.

Evolution of the surgical management of perihilar cholangiocarcinoma in a Western centre demonstrates improved survival with endoscopic biliary drainage and reduced use of blood transfusion.

BACKGROUND: Perihilar cholangiocarcinoma (PHCCA) remains a surgical challenge for which few large Western series have been reported. The aims of this study were to investigate the results of surgical resection for PHCCA and assess how practice has evolved over the past 15 years. METHODS: A prospectively maintained database was interrogated to identify all resections. Clinicopathological data were analysed for impact on survival. Subsequently, data for resections carried out during the periods 1994-1998, 1999-2003 and 2004-2008 were compared. RESULTS: Eighty-three patients underwent resection. Trisectionectomy was required in 67% of resections. Overall survival was 70%, 36% and 20% at 1, 3 and 5 years, respectively. Size of tumour, margin (R0) status, lymph node status, distant metastasis, tumour grade, portal vein resection, microscopic direct vascular invasion, T-stage and blood transfusion requirement significantly affected outcome on univariate analysis. Distant metastasis (P = 0.040), percutaneous biliary drainage (P = 0.015) and blood transfusion requirement (P = 0.026) were significant factors on multivariate analysis. Survival outcomes improved and blood transfusion requirement was significantly reduced in the most recent time period. DISCUSSION: Blood transfusion requirement and preoperative percutaneous biliary drainage were identified as independent indicators of a poor prognosis following resection of PHCCA. Longterm survival can be achieved following the aggressive surgical resection of this tumour, but the emergence of a clear learning curve in our analyses indicates that these patients should be managed in high-volume centres in order to achieve improved outcomes.

Index admission laparoscopic cholecystectomy for patients with acute biliary symptoms: results from a specialist centre.

BACKGROUND: Index admission laparoscopic cholecystectomy (ALC) is the treatment of choice for patients admitted with biliary symptoms but is performed in less than 15% of these admissions. We analysed our results for ALC within a tertiary hepatobiliary centre. METHODS: Data from all cholecystectomies carried out under the care of the two senior authors from 1998 to 2008 were prospectively collected and interrogated. RESULTS: 1710 patients underwent cholecystectomy of which 439 (26%) were ALC. Patients operated on acutely did not have a significantly different complication rate (P= 0.279; 4% vs.3%). Factors predicting complications were abnormal alkaline phosphatase (ALP) (P= 0.037), dilated common bile duct (CBD) (P= 0.026), cholangitis (P= 0.040) and absence of on table cholangiography (OTC) (P= 0.011). There were no bile duct injuries. Patients undergoing ALC had a higher rate of conversion to an open procedure (P < 0.001:10% vs.3%). The proportion of complicated disease was higher in the ALC group (P < 0.001; 70% vs.31%). Only complicated disease (P= 0.006), absence of OTC (P < 0.001) and age greater than 65 years (P < 0.001) were predictive of conversion on multivariate analysis. CONCLUSIONS: Laparoscopic cholecystectomy can be performed safely in patients with acute biliary symptoms and should be considered the gold standard for management of these patients thus avoiding avoidable readmissions and life-threatening complications. A higher conversion rate to an open procedure must be accepted when treating more complicated disease. It is the severity of disease rather than timing of surgery which most probably predicts complications and conversions.

Surgical treatment of hilar cholangiocarcinoma in a new era: comparison among leading Eastern and Western centers, Leeds.

OBJECTIVE: Surgery for hilar cholangiocarcinoma (HCCA) remains challenging, with radical procedures thought to offer the best chance of long-term survival. Here we present our data for surgical resection of HCCA for the period 2001-2008. METHODS: A prospectively maintained database was interrogated to identify all resections. Clinico-pathological data were analyzed and assessed for impact on survival. RESULTS: 51 patients were identified. Almost three-quarters required hepatic trisectionectomy. Overall survival was 76% at 1 year, 36% at 3 years and 20% at 5 years. When R0 resection was achieved, the 5-year survival was 40%. Portal vein resection, perineural invasion and T-stage were predictive of overall survival on univariate analysis. Only T-stage remained significant on multivariate analysis. Lymph node status predicted disease-free survival. CONCLUSION: Radical surgery continues to offer the prospect of long-term survival for patients with HCCA. Earlier detection and referral to tertiary centers may allow more patients to have potentially curative surgical resections.

Do smaller adults wait longer for liver transplantation? A comparison of the UK and the USA data.

BACKGROUND: The number of patients on the UK and the USA liver transplant list is increasing. As size match is an important factor in the UK organ allocation, we studied the effect of recipient size on liver transplantation in the UK and the USA. METHODS: The UK Transplant and United Network for Organ Sharing databases were used to assess difference in access to transplantation between smaller adult patients and their larger counterparts over three time periods. Subsequently, proportions of split, NHBD and living-donor transplants were analyzed. RESULTS: There were 1576 UK and 29,150 USA patients in our analysis. The UK small patients have been significantly disadvantaged in access to transplantation particularly in early years and in adult only transplant units. This contrasts to the USA where smaller patients have never been disadvantaged and transplantation rates are steadily increasing. Split-liver transplants are being carried out in increasing numbers in the UK but not the USA. CONCLUSIONS: Small adults are still less likely to be transplanted at six months in adult only units in the UK. The lack of size matched organs for smaller adults and the overall decrease in rates of transplantation in the UK may be remedied by careful consideration of allocation policy and increased use of innovative techniques.