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

2, which was declared a pandemic by the World Health Organization (WHO) on March 31 st. To date nearly 4 million cases have been documented

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.

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 <0.001 and 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/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.