Alessandro Tropea

Background: Robotic liver resections (RLRs) are rapidly expanding, yet the association between the learning curve, procedural complexity, and outcomes at intermediate-volume centers remains poorly defined. We evaluated the learning-curve trajectory and perioperative outcomes of a single surgeon’s initial RLR experience according to procedural complexity (IWATE difficulty score). Methods: We retrospectively analyzed 58 consecutive RLRs at an intermediate-volume center. We stratified outcomes by IWATE difficulty category and chronological tertile (early/middle/late). Textbook outcomes (TOs) and a composite failure endpoint (conversion, major complications [Clavien–Dindo ≥ IIIa] and 90-day mortality) were also assessed. Learning-curve behavior was examined with CUSUM and risk-adjusted CUSUM (RA-CUSUM) analyses. Results: Fifty-four procedures (93.1%) were minor resections and four were major hepatectomies; two were classified as IWATE Expert difficulty. Median estimated blood loss was 100 mL; conversion occurred in 10.3%, overall morbidity in 10.3% and severe complications (Clavien–Dindo ≥ IIIa) in 3.4%, with no mortalities within 90 days. TOs were achieved in 69.0% using the Delphi (TOLS) definition and in 46.6% using a length-of-stay-extended definition. Operative time and length of stay increased significantly with IWATE difficulty (p < 0.001 and p = 0.030), as did the composite failure endpoint (p = 0.039), whereas blood loss and complications did not. TOs decreased with difficulty under the extended definition (p = 0.016). No outcome except estimated blood loss differed across chronological tertiles (p = 0.032). Operative time was associated with the IWATE score (26.3 min per point; R² = 0.32) but not with case order (p = 0.93). CUSUM and RA-CUSUM curves showed a non-linear, multiphase pattern without an identifiable inflection point, with extremes attributable to individual high-complexity procedures. Conclusions: In this exploratory single-surgeon series, consisting predominantly of minor resections, no case-number threshold could be identified, and perioperative outcomes were more closely associated with procedural complexity than with chronological experience, supporting a complexity-adjusted interpretation of RLR outcomes rather than a fixed case-number learning threshold.

Background/Objectives: The increasing adoption of laparoscopic liver resection (LLR) and changes in clinical management may influence access to curative treatments for patients on the liver transplant waiting list. We aimed to analyze temporal trends in LLR use and to explore the association between the proportion of LLR and the dropout rate from the intention-to-treat (ITT) population. A secondary objective was to assess the risk of dropout or death versus curative treatment (transplantation or resection) in patients with hepatocellular carcinoma (HCC) compared with non-HCC candidates using a competing-risk model. Methods: We performed a retrospective cohort study of all patients listed for liver transplantation between 2015 and 2023. Annual rates of LLR and dropout were calculated, and their correlation was evaluated using Spearman’s rho. The risk of dropout/death and competing curative events (OLT, resection, or thermal ablation) was assessed using Fine–Gray competing-risk regression, adjusted for HCC status. Results: From 2015 to 2023, LLR accounted for a progressively increasing proportion of liver resections. A significant negative correlation was observed between annual LLR rates and dropout rates (ρ = −0.78, p = 0.008), indicating fewer ITT failures with greater LLR adoption. In the competing-risk analysis, HCC patients had a significantly lower subdistribution hazard for dropout/death (SHR 0.27, 95% CI 0.18–0.42, p < 0.001) and a higher probability of receiving a curative treatment (SHR 1.65, 95% CI 1.40–1.94, p < 0.001). Conclusions: The increased use of LLR was associated with improved access to curative therapies and a reduced dropout risk on the liver transplant waiting list. HCC patients showed a more favorable competing-risk profile compared with non-HCC candidates.

Metastatic colorectal cancer (mCRC) is a severe condition with high rates of illness and death. Current treatments are limited and not always effective because the cancer responds differently to drugs in different patients. This research aims to use artificial intelligence (AI) to improve treatment by predicting which therapies will work best for individual patients. By analyzing large sets of patient data and using machine learning, we hope to create a model that can identify which patients will respond to chemotherapy, either alone or combined with other targeted treatments. The study will involve dividing patients into training and validation sets to develop and test the models, avoiding overfitting. Various machine learning algorithms, like random survival forest and neural networks, will be integrated to develop a highly accurate and stable predictive model. The model’s performance will be evaluated using statistical measures such as sensitivity, specificity, and the area under the curve (AUC). The aim is to personalize treatments, improve patient outcomes, reduce healthcare costs, and make the treatment process more efficient. If successful, this research could significantly impact the medical community by providing a new tool for better managing and treating mCRC, leading to more personalized and effective cancer care. In addition, we examine the applicability of learning methods to biomarker discovery and therapy prediction by considering recent narrative publications.

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Background: Ischemia/reperfusion injury (IRI), acute rejection (AR), and delayed graft function (DGF) might occur as major complications following kidney transplantation. Thus, the identification of biomarkers for the IRI, AR, and/or DGF development becomes crucial as it may help to guide post-transplant management. Natural killer (NK) cells, hepatic interstitial T-lymphocytes (T-Li), and NK-T cells are crucial in both innate and adaptive immunity after abdominal solid organ transplantation. Hence, the aim of this study was to evaluate the impact of the immune system after graft reperfusion during KT in adults in order to identify predictive biomarkers. Methods: The NK, T-Li, and NK-T phenotypes and concentrations were retrospectively analyzed in a consecutive series of liver perfusates obtained after organ procurement flushing the abdominal cavity recovered from deceased brain donors (DBDs). Their percentage was compared with the renal transplant recipients’ characteristics with kidneys taken from the same DCDs. The hepatic perfusate cells were purified by density gradient centrifugation. Flow cytometric investigation was used to determine their phenotype with the following immunological markers in order to determine the relative percentage of T-Li, NK-T, and NK cells: CD3, CD4, CD8, and CD56. Results: 42 DBDs’ liver perfusates were analyzed. The related clinical outcomes of kidney transplant recipients from 2010 to 2020 performed at our Institute were evaluated. Time in days of delayed functional recovery of transplanted kidneys (DGF) (p = 0.02) and the onset of secondary infection from a cytomegalovirus (p = 0.03) were significantly associated with the T-Li percentage. An increased relative risk (HR) of organ survival was significantly associated with the percent cell concentration of T-Li and time to DGF, on COX analysis, were (HR = 1.038, p = 0.04; and HR = 1.029, p = 0.01, respectively). None relevant clinical outcomes in kidney transplant patients were associated with the specificity of the NK and NK-T cell proportions. Conclusions: A new potential role of T-Li cells was detected in the context of hepatic perfusate from DBDs. It could detect potential impacts in organ allocation, surgical procuring techniques, and in the analysis of IRI pathophysiological events.

Background: Hepatic interstitial T-lymphocytes (T-Li), Natural Killer (NK) and NK-T cells play an important role in both innate and adaptive immunity and contribute to the regulation of ischemia/reperfusion injury (IRI) after transplantation of abdominal organ. Methods: The cellular concentrations and phenotypes of NK, T-Li, NK-T were analyzed retrospectively in a consecutive series of hepatic perfusates after surgical removal of whole livers on the bench previously collected from adult multi-organ donors after brain death. (DBD), and compared with the demographic and pathological characteristics of the patients transplanted at our Institute with kidneys taken from the same donors. The liver interstitial cells were purified from the perfusate by density gradient centrifugation and the phenotype was determined by flow cytometric investigation using the following immunological markers: CD3, CD4, CD8 and CD56 in order to determine the relative percentage of T-Li, NK-T and NK cells. Results: The perfusates of 42 DBDs, and the related clinical outcome of kidney transplant recipients from 2010 to 2020, were analyzed. T-Li were significantly associated with the time in days of delayed functional recovery of transplanted kidneys (DGF) (p = 0.02), to onset of secondary infection from Cytomegalovirus (p = 0.03). On COX analysis, percent cell concentration of T-Li and time to DGF were significantly associated with an increased relative risk (HR) of organ survival (HR = 1.038, p = 0.04; and HR = 1.029, p = 0.01, respectively). The specificity of the NK and NK-T cell proportions were not associated with any relevant clinical outcomes in kidney transplant patients. Conclusions: The present study points to a new potential role of T-Li cells detected in the context of liver perfusate DBD, and could detect potential impacts in organ allocation, surgical harvesting techniques and in the analysis of IRI pathophysiological events after kidney transplants from multi-organ DBDs.

The use of expanded criteria donors is one of the strategies used to overcome the gap between the demand for organs and the number of donors. Physicians debate the extent to which marginal grafts can be used. In recent years, normothermic machine perfusion (NMP) has been used to test liver viability before transplantation. Grafts underwent NMP whenever histological steatosis was > 40% or there were at least three Eurotransplant criteria for expanded criteria donor (ECD). We used NMP to test 19 grafts, 3 from donation after type 3 controlled cardiac death (DCD), and 16 from donation after brain death (DBD). Only two grafts from DBD were not transplanted, because perfusion proved they were not suitable (total of 17 transplanted grafts of 19 tested grafts). Kaplan–Meier survival estimates at 30, 90, 180, and 1 year after transplant were all 94% (95% CI 84–100%); estimated 3-years survival was 82% (95% CI 62–100%). Overall survival rates did not differ from those of patients transplanted with non-perfused grafts from an ECD. In our experience, the use of very marginal grafts preventively tested by NMP does not negatively influence the patient’s outcome, and increases the number of transplants in low donation areas.

Background: Laparoscopic microwave thermal ablation (LMWTA) is a well-established alternative treatment to liver resection for treatment of liver tumors. The aim of this study was to describe our experience in LMWTA for hepatocellular carcinoma (HCC) in chronic hepatic patients. Materials and Methods: A study group of 61 consecutive HCC patients treated with LMWTA from January, 2013 to May, 2020 were considered for this study. Patient characteristics, liver function test, operational characteristics, and complications were recorded. Results: Of the 61 patients who underwent LMWTA, median age was 64 (interquartile range [IQR]: 58–71) years, mean body mass index was 26.2 (IQR: 23.2–29.4); 44 patients (72%) presented with an hepatitis C virus etiology, 46 (75%) were Child–Pugh Class A, median model for end-stage liver disease (MELD) score was 8.0 (IQR: 7.0–9.4). Viral infection was confirmed to be the most important risk factor in determining progressive cirrhotic evolution with HCC expression. Conclusions: LMWTA is a safe alternative treatment to traditional surgery, and can be combined with surgery.