Alessandro Furlanetto

Background: The RAPID procedure combines partial liver transplantation with delayed completion hepatectomy, allowing transplantation of small left-sided grafts while limiting living-donor hepatectomy. Although minimally invasive techniques are increasingly applied in liver transplantation, the second stage of RAPID has been performed through an open approach. We report a single-center case series of seven consecutive patients who underwent RAPID, with emphasis on laparoscopic second-stage completion hepatectomy. Methods: The RAPID procedure consists of left hepatectomy and implantation of a living-donor left lateral section or left lobe graft followed, after graft regeneration, by completion hepatectomy. Technical refinements include microwave ablation along the transection plane, reinforcement of the hepatic venous anastomosis with an autologous saphenous vein ring, and a laparoscopic approach to the second stage whenever technically feasible. The study was conducted within the RAPID-Padova protocol (NCT04865471). Results: Seven patients underwent RAPID: six for unresectable colorectal liver metastases and one for unresectable neuroendocrine liver metastasis. The median graft-to-body-weight ratio increased from 0.51% after step 1 to 0.92% before step 2, with a median graft-volume increase of 90%. Median time to step 2 was 19 days. Step 2 was completed laparoscopically in six of seven patients without conversion; one patient underwent a planned open completion hepatectomy to reposition and anchor the graft. Major complications (≥IIIa) occurred in five patients (median CCI 39.7), including three hepatic vein stenoses requiring endovascular stenting. Median follow-up was 30.7 months. Recurrence occurred in five of six patients with CRLM; 1-year and 3-year overall survival were 85.7% and 71.4%. Conclusions: In this selected series, laparoscopic completion hepatectomy within the RAPID procedure was technically feasible. No complication was directly attributable to the laparoscopic access, although the small sample does not allow a comparison with the open approach.

Objective: To determine whether multimodal predictive models incorporating task-level objective performance indicators (OPIs) alongside preoperative clinical variables improve prediction of surgeon experience, case complexity, and outcomes in robotic cholecystectomy. Background: OPIs from robotic platforms enable automated assessment of intraoperative performance, but prior multimodal analyses have suggested limited incremental value beyond clinical variables. Whether this conclusion holds when OPIs are computed at task level and target specifically curated endpoints remains untested. Methods: We retrospectively analyzed 234 Calot’s triangle dissections, 198 by attending surgeons and 36 by trainees. Three feature sets per target—clinical-only (10 preoperative variables), OPI-only (10 target-specific kinematic features), and combined—were evaluated using nested 5-seed×5-fold cross-validation across 5 algorithms (logistic regression, support vector machine, random forest, XGBoost, LightGBM). Discriminative performance was compared by paired Wilcoxon signed-rank tests on fold-level area under the receiver operating characteristic curve (AUROC). Feature contributions were quantified with SHapley Additive exPlanations (SHAP) analysis. Results: For surgeon experience and case complexity, OPIs alone matched the combined model (AUROC: 0.967 vs. 0.964; 0.791 vs. 0.792; both P >0.05) and outperformed clinical variables alone ( P P =0.006). For outcomes, the combined model significantly exceeded both single-modality models (AUROC: 0.753 vs. 0.720 clinical and 0.720 OPI-only; P =0.015 and 0.005). OPIs contributed 90.7%, 73.3%, and 51.7% of total absolute SHAP value across the 3 targets, decreasing with distance from intraoperative kinematics. Conclusions: Task-level, target-specific OPIs carry independent discriminative information beyond routine preoperative clinical variables. Their incremental value is target-dependent, with multimodal integration offering statistically significant but modest gains for outcomes.

Background: Non-colorectal cancer liver metastases (NCRLMs) represent a therapeutically challenging condition with poorly defined locoregional treatment options. This study evaluates the safety, oncological efficacy, and survival outcomes of microwave ablation (MWA) for NCRLMs in a large single-centre series. Methods: Retrospective analysis of patients undergoing MWA for NCRLM between January 2010 and December 2024 at a high-volume hepatobiliary centre. Endpoints were safety, efficacy, textbook outcome (TO) achievement, and overall survival (OS). Results: A total of 138 patients underwent 172 MWA procedures across eight primary tumour categories via a video-assisted (n = 110, 64%) or percutaneous (n = 62, 36%) approach. Major complications (Clavien–Dindo ≥ 3) occurred in 1.8% of procedures, with a median hospital stay of 2 days and a 90-day mortality of 1.7%. The median follow-up was 24.9 (10.3, 55.8) months. Complete response (CR) was achieved in 77% of procedures and TO in 54%, with incomplete response as the main driver of TO failure. The 5-year OS varied by histology, from 100% (GIST) and 80.0% (GEP-NET) to 44.7% (breast) and 0% (pancreatic adenocarcinoma). The video-assisted ablation was associated with superior OS compared to the percutaneous one (5-year OS 54.4% vs. 26.0%, p = 0.00025). In the multivariable analysis, the percutaneous approach (HR 2.44), ECOG PS ≥ 2 (HR 6.06) and a higher tumour burden score (HR 1.09) independently predicted worse OS, whereas the histological group was not independently associated with OS. Repeat MWA was the most frequent treatment for first hepatic recurrence, and 50% of patients reached no evidence of disease (NED) at last follow-up. Conclusions: MWA is a safe and repeatable locoregional treatment for NCRLMs, with outcomes shaped by tumour biology, disease burden, patient fitness and procedural approach. The high rate of liver-dominant recurrence treated with repeat MWA, combined with a final NED rate of 50%, supports MWA as a platform for iterative locoregional disease control in selected patients.

Liver transplantation for cholangiocarcinoma (CCA) shifted from a contraindication to a promising therapeutic option for selected patients. Advances in neoadjuvant therapy and refined selection criteria resulted in long-term outcomes comparable to other accepted oncologic indications, particularly in perihilar CCA managed with standardized protocols and in intrahepatic CCA with favorable tumor biology. The future challenge is to develop a multiparametric biological selection, blending clinical, functional, histopathologic, molecular, and radiologic parameters to identify candidates with indolent disease behavior, thus maximizing oncologic benefit while ensuring appropriate use of limited graft resources.

Background: Non-colorectal cancer liver metastases (NCRLM) represent a therapeutically challenging condition with poorly defined locoregional treatment options. This study evaluates the safety, oncological efficacy, and survival outcomes of microwave ablation (MWA) for NCRLM in a large single-centre series. Methods: Retrospective analysis of a prospectively collected database of patients undergoing MWA for NCRLM between January 2010 and December 2024 at a high-volume hepatobiliary centre. Endpoints were safety, efficacy, Textbook Outcome (TO) achievement, and overall survival (OS). Results: A total of 138 patients underwent 172 MWA across eight primary tumour categories. Major complications (Clavien-Dindo≥3) occurred in 1.8% of procedures, with a median hospital stay of 2 days and a 30-day mortality of 0.6%. Complete response (CR) was achieved in 77% of procedures. TO was achieved in 54% of procedures, with incomplete CR as the primary driver of failure. Five-year OS varied markedly by histology: 100% for GIST, 80.0% for GEP-NET, 44.7% for breast cancer, and 0% for pancreatic adenocarcinoma. The video-assisted approach was associated with superior OS compared to percutaneous ablation (5-year OS 54.4% vs. 26.0%, p=0.00025). Repeat MWA was the most frequent treatment for first hepatic recurrence (43%), and 50.0% of patients achieved non-evidence of disease (NED) at final follow-up. Conclusions: MWA is a safe and repeatable locoregional treatment for NCRLM, with outcomes driven by primary tumour biology. The high rate of liver-dominant recurrence treated with repeat MWA, combined with a final NED rate of 50%, supports MWA as a platform for iterative locoregional disease control in selected patients.

Background/Objectives: Salvage liver transplantation (SLT) is a well-established option for hepatocellular carcinoma (HCC) recurrence after liver resection. Laparoscopic microwave ablation (L-MWA) represents another curative strategy for early-stage HCC. However, its role within this therapeutic framework remains unexplored. Methods: Between 2014 and 2023, we treated 1341 patients with HCC using L-MWA. From this cohort, patients with Child-Pugh class A liver function, HCC within the Milan criteria, no contraindications to transplantation, and ≥12 months of follow-up were selected. SLT failure was defined as non-transplantable recurrence or death, resulting in the loss of a potentially curative therapeutic opportunity. The primary endpoint was overall survival (OS); secondary endpoints included predictors of survival and SLT failure. Results: A total of 341 patients met the inclusion criteria. Five-year OS was 62%. Independent predictors of poorer survival included the presence of cardiac disease or oesophageal varices, a Child-Pugh score of 6, tumour size, and elevated alpha-fetoprotein (AFP) levels. Treatment was successful in 255 patients (74.8%): 102 (29.9%) underwent SLT, 67 (19.6%) received alternative therapies, and 93 (27.3%) remained recurrence-free. Treatment failure occurred in 86 patients (25.2%) due to non-transplantable recurrence or death. Independent predictors of failure included older age, non-HBV aetiology, and elevated AFP levels. Five-year OS rates were 79% in the success group and 22% in the failure group (p < 0.001). Conclusions: A combined L-MWA and SLT strategy is safe and effective, yielding a 62% 5-year OS rate. This approach supports more efficient graft use with a consequent increase in the population transplant benefit. Improved selection may further reduce failure rates.

Total hepatectomy and liver transplantation has emerged as a game-changing strategy in the treatment of several liver-confined primary or metastatic tumors, opening the new era of transplant oncology. However, the expansion of indications is going to worsen the chronic scarcity of organs, and new strategies are needed to enlarge the donor pool. A possible source of organs could be developing split liver transplantation (SLT) programs. We propose to refer donors aged 18-50 years unsuitable for pediatric patients and donors aged 50-60 years for split evaluation. This will generate new small left lateral grafts that can be used for RAPID procedures, based on a national waiting list specifically for non-HCC oncologic patients. Centralized imaging review will streamline the donor-recipient matching process and address organizational challenges. Additionally, adopting an ex-situ splitting technique during hypothermic oxygenated machine perfusion could further enhance logistical efficiency and improve graft viability. The proposed protocol (ALERT 50) will therefore promote the development of oncologic indications without affecting the standard waiting list and without competing with urgent or pediatric patients. Export

Liver transplantation (LT) was considered an ineffective treatment for perihilar cholangiocarcinoma (pCCA) until the successful experience of the Mayo Clinic, proposing a protocol with strict inclusion criteria and neoadjuvant radio-chemotherapy. Since 2015, pCCA is considered an indication for LT in Italy only in the context of controlled prospective studies. We performed a survey among the 22 Italian Liver Transplant Centers to assess the results of LT for pCCA. Eight centers reported 53 cases from 1986 to 2021 (Bologna 12, Padova 10, Niguarda 10, Milano Tumori 8, Torino 5, Pisa 4, Ancona 2, Modena 2). Patients were divided according to whether they recieved neoadjuvant radio-chemotherapy (Group 1, 25 cases) or not (Group 2, 28 cases). Eleven patients were transplanted without neoadjuvant treatment after 2015. Overall survival at 1, 3 and 5 years was 83.8%, 56.6% and 50.6% in Group 1 and 72.4%, 41.4% and 35.5% in Gropu 2 (p = 0.13). Recurrence-free survival at 1, 3, and 5 years was 91.2%, 61.1% and 47.2% in Group 1 and 58.2%, 42.2%, and 36.1% in Group 2 (p = 0.16). A competing risk regression analysis showed a 5-year risk of cancer-related death of 19% for patients in Group 1 against 62.3% in Group 2, with a hazard ratio of 0.31 (95%CI [0.10–0.98], p 0.047). This survey promoted a discussion about the limitations of the Mayo protocol and set the basis for the adoption of a new nationwide protocol (LITHALICA–NCT06125769), having the same inclusion criteria but proposing standard of care chemotherapy as neoadjuvant regimen.