Living donor liver transplantation (LDLT) is a treatment option for select patients with unresectable colorectal liver metastasis (uCRLM). We describe our center's experience of patient selection, insurance approval, and outcomes after LDLT after first referral in March 2019. Of the 206 evaluated patients, twenty-three underwent LDLT. We found that patients who were referred earlier in their oncologic course were more likely to be eligible for transplantation. After completion of the Rochester Protocol for LDLT eligibility, recipients had a median delay of care of 10 days (IQR 0-36) related to insurance appeal, with six patients (30%) having a delay longer than 30 days. LDLT recipients had an overall survival proportion of 100% and 91% at 1, and 3 years; and a recurrence-free survival proportion of 100% and 40%, at 1 and 3 years, respectively. All donors underwent right hepatectomy, of which only one donor had a Clavien-Dindo IIIa complication and readmission. There was no donor mortality. We assert that multidisciplinary care and strict patient selection through the Rochester Protocol were paramount to our center's success. In the appropriately selected patient, LDLT for uCRLM may be justified, and patients should be referred to transplant oncology centers for evaluation.

Background: Histotripsy is a novel, non-invasive, focused ultrasound therapy that mechanically disrupts targeted tissues through cavitation, offering a precise and non-thermal alternative to conventional locoregional therapies with preservation of vascular and biliary structures. There are limited reports on the early use of histotripsy in primary and secondary liver tumors. Materials and Methods: Patients undergoing histotripsy for the treatment of primary and secondary liver tumors were retrospectively analyzed. The response to histotripsy was evaluated by assessing computed tomography findings in the first 3 months post-procedure period. Results: Twenty-seven patients were included in the study. Nine (33%) received histotripsy with downstaging or bridging intent, whereas 18 (67%) received histotripsy as part of a palliative treatment approach. Among patients with downstaging or bridging intent, seven of eight (87.5%) evaluable patients showed no lesion growth ≤3 months post-procedure. In palliative patients, growth remained controlled during the first 3 months in three of nine (33%) cases, while increasing in the remaining six (67%). Interestingly, tumoral size decreased in tumors not targeted by histotripsy in four patients, including one palliative patient who was not responding to multiple prior treatments. After histotripsy, three patients were successfully downstaged for liver resection and five were eligible for liver transplantation. Conclusion: Histotripsy presents great potential for the treatment of liver tumors, achieving high rates of short-term local disease control while offering vascular and biliary protection advantages, unlike thermal methods. Further work is required to understand a possible response away from the target. Histotripsy, in combination with systemic therapies, could aid in bridging or downstaging patients with advanced disease to achieve surgical resection or transplantation.

Transplant oncology is a rapidly evolving discipline that incorporates oncology, transplant medicine, and surgery. As the field continues to grow, there remains an opportunity to enhance patient selection, detect recurrence after liver transplantation, and optimize treatment after recurrence. Liquid biopsies are an emerging resource to improve patient care. In this review, we evaluate the most recent available data on circulating tumor DNA and how it pertains to primary and metastatic hepatobiliary malignancies. We discuss the opportunities and current limitations to clinical practice, especially in relation to total hepatectomy and liver transplantation. We conclude that as both transplant oncology and our understanding of circulating tumor DNA continue to evolve, rigorous, prospective study is required to integrate this technology into a clinical paradigm.

The aims of this study were to evaluate the outcomes of patients undergoing kinematic alignment (KA) robot-assisted (RA) total knee arthroplasty (TKA) with and without preoperative fixed flexion contracture (FFC) and address whether additional resection of the proximal tibia is required to address FFC. A retrospective review from 147 consecutive patients who received an RA-TKA with KA and a minimum one-year follow-up was performed. Preop and postop clinical and surgical data were collected. Groups were set based on preoperative extension deficits: group 1 (0–4°) (n = 64), group 2 (5–10°) (n = 64) and group 3 (>11°) (n = 27). There were no differences in patient demographics among the three groups. In group 3, the mean tibia resection was 0.85 mm thicker than group 1 (p < 0.05) and the preoperative extension deficit was improved from −17.22° (SD 3.49) preop to −2.41° (SD 4.47) postop (p < 0.05). Our results demonstrate that FFC can successfully be addressed in the RA-TKA with KA and rKA and that no additional femoral bone resection is needed to achieve full extension in patients with preoperative FFC when compared with patients without FFC. Only a slight increase in the amount of tibial resection was observed, but this was less than one millimetre.

Background: Instability is a common cause of (total knee arthroplasty) TKA failure, which can be prevented by achieving proper gap balance during surgery. There is no consensus on the ideal gap balance in TKA, and different alignment philosophies result in varying soft-tissue tightness. Traditional TKA aims for symmetric compartment balance, while kinematic alignment (KA) restores anatomy and accepts asymmetric flexion gaps. This study evaluated the impact of these philosophies on the flexion gap balance and clinical outcomes. Methods: A retrospective review of 167 patients who received true or restricted KA robotic-assisted TKA with at least one year of follow-up was conducted. The groups were based on intraoperative flexion gap differences: symmetric (0–1 mm) (n = 94) and asymmetric (2–5 mm) (n = 73). Results: Preoperative demographics and postoperative clinical and functional scores were compared. Both groups were similar in demographics and preoperative scores. True KA alignment was more likely to result in an asymmetric flexion gap, while restricted KA produced symmetric gaps. Conclusions: The study found no adverse effects from the physiological asymmetric flexion gap, with clinical and functional outcomes comparable to symmetric gaps. A 5 mm difference between the medial and lateral gap width did not negatively impact the outcomes. True KA more frequently results in a physiological asymmetric flexion gap.

The TransMet trial and Norwegian studies have shown excellent outcomes in highly selected patients undergoing liver transplant (LT) for unresectable colorectal liver metastases (uCRLM). Our aim is to provide an updated analysis of the current state of LT for uCRLM in the United States. Adult patients with a diagnosis of uCRLM listed for LT between December 2017 and March 2025 were identified from the United Network for Organ Sharing database and analyzed. An analysis of living donor LT (LDLT) and deceased donor LT (DDLT) was performed. During this period, 222 patients were listed, and 158 received an LT across 33 centers. Of these, 76 (48.1%) underwent LDLT, and 82 patients (51.9%) underwent DDLT. Of the 82 deceased donors, 56 (68.2%) were out-of-sequence offers. Overall, the 3-year survival and disease-free survival rates were 66.7% and 44.0%, respectively. The 3-year survival for LDLT and DDLT was 74.1% and 57.3% ( p =0.04), respectively. While these results have not yet reached the acceptable threshold established for other LT indications, they have improved and are expected to continue improving after the implementation of prioritization points. Given the potential variability of oncologic selection criteria and graft quality, we call for the standardization of nationally accepted selection criteria for listing patients for LT with uCRLM and for providing early access to high-quality organs. To achieve this, it is imperative to create, update, and maintain national databases that allow for the collection of more granular oncological variables.