Solid organ transplantation remains limited by the availability and quality of donor organs. Despite advances in donor management and allocation policy, a substantial proportion of recovered organs are discarded, and increasing reliance on extended-criteria and donation after circulatory death donors introduces additional uncertainty regarding graft viability. Traditional preservation using static cold storage provides a limited opportunity to assess organ function or intervene therapeutically before transplantation. Recent advances in machine perfusion technologies have begun to reshape this paradigm by enabling donor organs to be maintained and evaluated ex vivo. Normothermic perfusion platforms allow real-time physiologic assessment and biochemical monitoring, while hypothermic approaches primarily support preservation with more limited capacity for functional evaluation. These capabilities have created the foundation for the development of organ assessment and repair centers (ARCs), specialized platforms designed to centralize perfusion-based organ evaluation and potential rehabilitation. This overview examines the rationale for regionalized ARC systems and their potential to expand donor organ utilization while improving graft preservation and viability assessment. We discuss the clinical and logistical advantages of centralized perfusion platforms, including mitigation of ischemia/reperfusion injury, improved viability assessment, centralized expertise, integrated research infrastructure, and opportunities for organ-directed therapeutic interventions. We also examine the practical challenges associated with ARC implementation, including financial costs, infrastructure requirements, regulatory oversight, and logistical coordination across transplant networks. As machine perfusion technologies continue to evolve, ARCs may provide the infrastructure needed to integrate advanced preservation, diagnostics, and therapeutic interventions into routine transplant practice, enabling more effective utilization of the donor organ pool.

Objective: We sought to assess the outcomes of octogenarians compared to a reference group of younger patients undergoing robotic anatomic lung resection for non-small cell lung cancer (NSCLC) to better understand the postoperative expectations of this elderly patient population. Methods: A prospectively maintained Institutional General Thoracic Surgery Database was queried for patients aged 80 years and above (octogenarians) and 65–75 years (reference group) undergoing robotic lobectomy or segmentectomy for NSCLC between 2015 and 2026. Clinical data and postoperative outcomes were collected and compared using both unadjusted and 1:1 propensity-score matching. Results: In total, 822 patients were identified: 101 in the octogenarian group (mean age 82.4 years [standard deviation 2.2]) and 721 in the reference group (69.7 [3.1], p < 0.001). Postoperative complications that were more frequent in octogenarians included pneumothorax requiring chest tube insertion (5.9% vs. 2.2%, p = 0.043), atrial arrhythmias (18.8% vs. 9.2%, p = 0.005), and urinary tract infections (6.9% vs. 1.7%, p = 0.005). Air leak, atelectasis, pneumonia, respiratory failure, pleural effusion, empyema, and delirium did not differ between the groups. After propensity matching, there were no significant differences in the aforementioned postoperative outcomes. While the unadjusted length of stay was longer in octogenarians (4 days [interquartile range 3–5] vs. 3 [2–5], p = 0.012), this was no longer significant after matching (4 [3–5] vs. 3 [2–5], p = 0.369). There were no statistically significant differences in 30-day readmission rates (p = 0.197) or 30-day mortality (p = 0.781) after propensity-score matching. Conclusions: Among carefully selected octogenarians undergoing robotic anatomic lung resection for NSCLC, no statistically significant differences in short-term postoperative outcomes were detected compared with patients aged 65–75 years after adjustment for baseline differences. These findings support individualized surgical selection beyond chronologic age alone.

Accurate donor-recipient allograft size matching remains a critical determinant of outcomes in lung transplantation, yet current approaches rely predominantly on predicted total lung capacity (pTLC) and height-based metrics derived from population-based equations. These simplified surrogates fail to capture individual anatomical variability, disease-specific alterations in thoracic geometry, and the spatial relationship between donor lungs and recipient chest cavities. In this review, we examine the limitations of conventional size matching and synthesize emerging evidence supporting imaging-based approaches, including computed tomography (CT) volumetry, radiomics, and machine learning. CT-derived volumetric analysis enables individualized anatomical assessment and has been associated with clinically relevant prediction of primary graft dysfunction and mortality. Advanced computational methods may further support extraction of imaging-derived features and integration with clinical data, although these approaches remain investigational. Collectively, these developments signal a paradigm shift from crude population-based metrics toward imaging-driven and computational approaches in the modern era. With rigorous validation and careful clinical integration, imaging-based approaches may complement conventional size metrics and support more individualized donor-recipient assessment.