Carlo Pulitano

• MD, PhD, FRACS
• Professor (Associate) at Royal Prince Alfred Hospital

Background The role of anatomic resection (AR) versus non-anatomic resection (NAR) for intrahepatic cholangiocarcinoma (ICC) has not been thoroughly investigated. This study sought to define the impact of tumor size on the relative therapeutic benefit of AR versus NAR for ICC. Specifically, the study aimed to identify a threshold tumor size to defi...

Indocyanine green fluorescence-guided axillary sentinel lymph node biopsy.

Background Liver resection for multifocal intrahepatic cholangiocarcinoma (ICC) remains controversial due to a poor prognosis, driven by aggressive tumour biology. The aim of this study was to stratify multifocal ICC patients to identify those who are likely to benefit from resection. Methods Patients who underwent upfront curative-intent hepatect...

More liver transplants (LT) are performed worldwide thanks to extended criteria donors (ECD). This is paralleled by a supposed increased risk of allograft failure (AF) at 90 and 365 days. This study has been designed to portray the LT practice worldwide and investigate models of AF prediction and the impact of risk mitigation strategies for further...

Introduction The role of recurrence-free survival (RFS) as a validated surrogate endpoint for overall survival (OS) among patients undergoing upfront surgery for intrahepatic cholangiocarcinoma (ICC) has not been defined. We sought to evaluate the correlation between RFS and OS after surgical resection for ICC. We hypothesized that RFS was a reliab...

Background/Aims: Biliary complications are a leading cause of morbidity after liver transplantation, but can be reduced using real-time assessment of the biliary tree. This study described a novel technique for performing ex vivo cholangioscopy during cold static storage and normothermic machine perfusion (NMP) to assess the biliary tree before liv...

Introduction While postoperative adjuvant chemotherapy (AC) is generally recommended for intrahepatic cholangiocarcinoma (ICC), its benefit remains debated. This study aimed to identify patients that may benefit from AC following liver resection of ICC. Methods Patients who underwent liver resection for ICC between 2000 and 2023 were identified fr...

Background The global shortage of suitable donor livers for transplantation has prompted efforts to expand the donor pool by using extended criteria donors. Machine preservation technology has shown promise in optimizing graft preservation and improving logistics. Additionally, it holds potential for organ repair, regeneration, therapeutic applicat...

Background The feasibility of trials in liver surgery using a single-component clinical endpoint is low because single endpoints require large samples due to their low incidence. The current study sought to develop and validate a novel composite endpoint of liver surgery (CELS) to facilitate the generation of more feasible and robust high-level evi...

Background Access to liver transplantation (LT) is affected by geographic disparities. Higher waitlist mortality is observed in patients residing farther from LT centres, but the impact of distance on post‐LT outcomes is unclear. Aims To evaluate whether the distance LT recipients reside from their LT centre affects graft and patient outcomes. Me...

Background: Although there is evidence that indocyanine green angiography (ICGA) can predict mastectomy skin flap necrosis during breast reconstruction, consensus on optimal protocol is lacking. This study aimed to evaluate various technical factors which can influence ICG fluorescence intensity and thus interpretation of angiograms. Method: Single...

Recent advances in machine perfusion have revolutionised the field of transplantation by prolonging preservation, permitting evaluation of viability prior to implant and rescue of discarded organs. Long-term perfusion for days-to-weeks provides time to modify these organs prior to transplantation. By using long-term normothermic machine perfusion t...

The prognostic role of the fibrosis-4 (FIB-4) index relative to intrahepatic cholangiocarcinoma (ICC) after hepatectomy remains unclear. This study sought to characterize the impact of the FIB-4 index and tumor burden score (TBS) on recurrence and overall survival (OS). ICC patients undergoing hepatectomy (2000–2020) were identified using a multi-i...

Background HCC develops in the context of chronic inflammation; however, the opposing roles the immune system plays in both the development and control of tumors are not fully understood. Mapping immune cell interactions across the distinct tissue regions could provide greater insight into the role individual immune populations have within tumors....

Background and Objectives Among patients undergoing liver resection for intrahepatic cholangiocarcinoma (ICC), perioperative bleeding requiring blood transfusion is a common complication, yet preoperative identification of patients at risk for transfusion remains challenging. The objective of this study was to develop a preoperative risk score for...

Background and Objectives An elevated platelet count may reflect neoplastic and inflammatory states, with cytokine‐driven overproduction of platelets. The objective of this study was to evaluate the prognostic utility of high platelet count among patients undergoing curative‐intent liver surgery for intrahepatic cholangiocarcinoma (ICC). Methods A...

Introduction: Bile duct regeneration is hypothesised to prevent biliary strictures, a leading cause of morbidity after liver transplantation. Assessing the capacity for biliary regeneration may identify grafts as suitable for transplantation that are currently declined, but has been unfeasible until now. This study used Long-Term Ex-Situ Normotherm...

Background Hypothermic Oxygenated machine PErfusion (HOPE) can reduce ischemic reperfusion injury and improve outcomes for liver transplant recipients. However, the effect of HOPE on high‐risk extended criteria donor (ECD) and donation after circulatory death determination (DCDD) grafts is incomplete, despite the expectation that this cohort benefi...

Objectives The objective of the current study was to characterize prognostic factors related to long‐term recurrence‐free survival after curative‐intent resection of intrahepatic cholangiocarcinoma (ICC). Methods Data on patients who underwent curative‐intent resection for ICC between 2000 and 2020 were collected from an international multi‐instit...

Introduction Immediate post-mastectomy breast reconstruction offers benefits; however, complications can compromise outcomes. Intraoperative indocyanine green fluorescence angiography (ICGFA) may mitigate perfusion-related complications (PRC); however, its interpretation remains subjective. Here, we examine and develop methods for ICGFA quantificat...

Background Acute allograft rejection is a well-known complication of liver transplantation (LT). The incidence, epidemiology and outcomes of acute rejection have not been well-described in Australia. Methods We retrospectively studied consecutive adults who underwent deceased-donor LT at a single centre between 2010-2020. Donor and recipient data...

Background Normothermic machine perfusion (NMP) allows for the assessment and resuscitation of ex‐vivo human livers prior to transplantation. Commercially available NMP systems are closed circuits that accumulate metabolic waste and cytokines over time, potentially limiting organ preservation times. Dialysis has been proposed as a method to remove...

Although up to 50–70% of patients with intrahepatic cholangiocarcinoma (ICC) recur following resection, data to predict post-recurrence survival (PRS) and guide treatment of recurrence are limited. Patients who underwent resection of ICC between 2000 and 2020 were identified from an international, multi-institutional database. Data on primary disea...

Developing clinically predictive model systems for evaluating gene transfer and gene editing technologies has become increasingly important in the era of personalized medicine. Liver-directed gene therapies present a unique challenge due to the complexity of the human liver. In this work, we describe the application of whole human liver explants in...

Introduction Data on clinical characteristics and disease-specific prognosis among patients with early onset intrahepatic cholangiocarcinoma (ICC) are currently limited. Methods Patients undergoing hepatectomy for ICC between 2000 and 2020 were identified by using a multi-institutional database. The association of early (≤50 years) versus typical...

The evolution of indocyanine green (ICG) fluorescence in breast and axilla surgery from an Australasian perspective is discussed in this narrative review with a focus on breast cancer and reconstruction surgery. The authors have nearly a decade of experience with ICG in a high-volume institution, which has resulted in publications and ongoing futur...

Introduction Benchmarking in surgery has been proposed as a means to compare results across institutions to establish best practices. We sought to define benchmark values for hepatectomy for intrahepatic cholangiocarcinoma (ICC) across an international population. Methods Patients who underwent liver resection for ICC between 1990 and 2020 were id...

Background Ex situ machine perfusion facilitates the assessment of livers prior to transplantation. However, currently available markers of liver function poorly predict long‐term graft function. Indocyanine green (ICG) is a liver‐specific dye which, although common in vivo, has never been comprehensively evaluated for the assessment of graft quali...

Dynamic organ preservation is a relatively old technique which has regained significant interest in the last decade. Machine perfusion (MP) techniques are applied in various fields of solid organ transplantation today. The first clinical series of ex situ MP in liver transplantation was presented in 2010. Since then, the number of research and clin...

The aims of this study were to assess patient-reported outcomes and the survival of patients following curative resection for pancreas cancer. Adult patients undergoing curative pancreatic resection between April 2014 and April 2019 across six major hospitals in Sydney were invited to complete the Short-Form 36 (SF-36v2) and the Functional Assessme...

Intrahepatic cholangiocarcinoma (ICC) constitutes a group of heterogeneous malignancies within the liver. We sought to subtype ICC based on anatomical origin of tumors, as well as propose modifications of the current classification system. Patients undergoing curative-intent resection for ICC, hilar cholangiocarcinoma (CCA), or hepatocellular carci...

Introduction: Histological injury to the biliary tree during organ preservation leads to biliary strictures after liver transplantation. The Bile Duct Injury (BDI) score was developed to assess histological injury and identify the grafts most likely to develop biliary strictures. The BDI score evaluates the bile duct mural stroma, peribiliary vascu...

Background & Aims: Hepatocellular carcinoma (HCC) develops in the context of chronic inflammation, however, the opposing roles the immune system plays in both the development and control of tumours is not fully understood. Mapping immune cell interactions across the distinct tissue regions could provide greater insight into the role individual immu...

Current machine perfusion technology permits livers to be preserved ex situ for short periods to assess viability prior to transplant. Long-term normothermic perfusion of livers is an emerging field with tremendous potential for the assessment, recovery, and modification of organs. In this study, we aimed to develop a long-term model of ex situ per...

Developing clinically predictive model systems for evaluating gene transfer and gene editing technologies has become increasingly important in the era of personalized medicine. Liver-directed gene therapies present a unique challenge due to the complexity of the human liver. In this work, we describe the application of whole human liver explants in...

Developing clinically predictive model systems for evaluating gene transfer and gene editing technologies has become increasingly important in the era of personalized medicine. Liver-directed gene therapies present a unique challenge due to the complexity of the human liver. In this work, we describe the application of whole human liver explants in...

Background The methods for sentinel lymph node (SLN) biopsy in breast cancer have been variable in type and number of tracers. Some units have abandoned the use of blue dye (BD) due to adverse reactions. Fluorescence-guided biopsy with indocyanine green (ICG) is a relatively novel technique. This study compared the clinical efficacy and costs betwe...

Periosteum is a highly vascularized membrane lining the surface of bones. It plays essential roles in bone repair following injury and reconstruction following invasive surgeries. To broaden the use of periosteum, including for augmenting in vitro bone engineering and/or in vivo bone repair, we have developed an ex vivo perfusion bioreactor system...

Background: Liver transplantation is a lifesaving procedure for patients with end-stage liver disease (ESLD). However, many patients never receive a transplant due to insufficient donor supply. Historically, organs have been preserved using static cold storage (SCS). However, recently, ex vivo normothermic machine perfusion (NMP) has emerged as an...

Background The high incidence of early recurrence after hepatectomy for intrahepatic cholangiocarcinoma (ICC) has a detrimental effect on overall survival (OS). Machine-learning models may improve the accuracy of outcome prediction for malignancies.Methods Patients who underwent curative-intent hepatectomy for ICC were identified using an internati...

Background: Normothermic machine perfusion permits the ex vivo preservation of human livers before transplantation. Long-term perfusion for days-to-weeks provides the opportunity for enhanced pretransplant assessment and potential regeneration of organs. However, this risks microbial contamination and infection of the recipient if the organ is tra...

Background: The prognostic impact of major postoperative complications (POCs) for intrahepatic cholangiocarcinoma (ICC) remains ill-defined. We sought to analyze the relationship between POCs and outcomes relative to lymph node metastases (LNM) and tumor burden score (TBS). Methods: Patients who underwent resection of ICC between 1990-2020 were...

Introduction: Incisional hernia is a common complication following liver transplantation occurring in 5%-34% of patients. Traditionally, open repair was standard due to fear of abdominal adhesions, postoperative complications and lack of experience with laparoscopic techniques. Laparoscopic incisional hernia repair (LIHR) has now become routine in...

Background: Intrahepatic cholangiocarcinoma (ICC) is associated with poor long-term outcomes, and limited evidence exists on optimal resection margin width. This study used artificial intelligence to investigate long-term outcomes and optimal margin width in hepatectomy for ICC. Methods: The study enrolled patients who underwent curative-intent...

Current perfusion technology only allows livers to be preserved ex-vivo for short periods. Long-term normothermic perfusion of livers is an emerging field with tremendous potential for the assessment, recovery, and modification of organs. In this study, we aimed develop a long-term model of ex-vivo perfusion including a surgical split and simultane...

Unlabelled: Biliary complications are a common cause of morbidity after liver transplantation and associated with bile duct injury. To reduce injury, a bile duct flush is performed with high-viscosity preservation solution. It has been suggested that an earlier additional bile duct flush with low-viscosity preservation solution may reduce bile duc...

Background: Split liver transplantation permits the transplant of two recipients using a single donor liver. Liver splitting can be performed using the ex-vivo technique (more convenient), or the in-situ technique (shorter cold ischaemic time). We aimed to develop a technique for liver splitting during normothermic machine perfusion which combines...

Introduction: Demand for donor kidneys far exceeds the availability of organs from deceased donors. Living donor kidneys are an important part of addressing this shortfall, and laparoscopic nephrectomy is an important strategy to reduce donor morbidity and increase the acceptability of living donation. Aim: To retrospectively review the intraope...

Background: The therapeutic role of lymphadenectomy (LND) for intrahepatic cholangiocarcinoma (ICC) patients remains ill-defined. We sought to analyze the therapeutic value of LND relative to tumor location and preoperative lymph node metastasis (LNM) risk. Methods: Patients who underwent curative-intent hepatic resection of ICC between 1990 and...

Background The prognostic role of tumor burden score (TBS) relative to albumin-bilirubin (ALBI) grade among patients undergoing curative-intent resection of ICC has not been examined.Methods We identified patients who underwent curative-intent resection for ICC between 1990 and 2017 from a multi-institutional database. Multivariable analysis was pe...

Background: The interplay of CA19-9 and tumor burden score (TBS) in intrahepatic cholangiocarcinoma (ICC) remains ill-defined. We evaluated the role of TBS and CA19-9 relative to overall survival (OS) and recurrence, as well as the predictive ability of the Combination of TBS and CA 19-9 (CTC) grading system. Study design: Patients who underwent...

Background: Indocyanine green angiography (ICGA) aims to reduce ischaemic complications by supplementing intraoperative perfusion assessment of mastectomy flaps. Learning curves for this technology have not been analysed. We evaluated changes in patient outcomes with increasing case volume after ICGA adoption in postmastectomy reconstruction. Met...

Background We sought to investigate whether the unique lateral patterns of lymphatic drainage impacted lymphadenectomy (LND), lymph node metastasis (LNM), and long-term survival of patients after curative hemi-hepatectomy for left- versus right-sided intrahepatic cholangiocarcinoma (ICC). Methods Data on patients who underwent curative hemi-hepatec...

Background: The present study aimed to examine the prognostic significance of margin status following hepatectomy of intrahepatic cholangiocarcinoma (ICC) relative to overall tumor burden and nodal status. Method: Patients who underwent curative-intent surgery for ICC between 1990 and 2017 were included from a multi-institutional database. The i...

IntroductionWhile generally associated with poor prognosis, intrahepatic cholangiocarcinoma (ICC) can have a heterogeneous presentation and natural history. We sought to identify specific ICC subtypes that may be associated with varied long-term outcomes and patterns of recurrence after liver resection.Methods Patients who underwent curative-intent...

Introduction The aim of this study was to develop a predictive model to identify individuals most likely to derive overall survival (OS) benefit from adjuvant chemotherapy (AC) after hepatic resection of intrahepatic cholangiocarcinoma (ICC). Methods Patients who underwent hepatic resection of ICC between 1990-2020 were identified from a multi-ins...

Factor V deficiency is a congenital bleeding diathesis that, in selected cases, may be managed with liver transplant. In this case, we describe the treatment of an adult patient with kidney failure secondary to juvenile onset polycystic kidney disease who received a combined liver-kidney transplant as a method to manage the risks associated with th...

Background Vessels that encapsulate tumor clusters (VETC) is a novel vascular pattern seen on hepatocellular carcinoma (HCC) histology which has been shown to independently predict tumor recurrence and survival after liver resection. Its prognostic value in HCC patients receiving liver transplantation (LT) is unclear. Methods We retrospectively st...

Introduction: Current ex-vivo technology allows the perfusion of an organ only for a number of hours. There is a need for perfusion in the range of days-to-weeks to facilitate sophisticated assessment, recovery and modification of these organs. Normothermic perfusion of livers longer than 1 week has never been previously described. In this study, w...

PurposeTo investigate recurrence patterns after surgery for intrahepatic cholangiocarcinoma (ICC) relative to lymph node status, tumor extension, tumor burden score (TBS), and adjuvant chemotherapy.Methods Patients who underwent curative-intent resection for ICC from 1990 to 2020 were enrolled from a multi-institutional database. The hazard functio...

In this case report, we preserved human livers for up to 13 days under normothermic conditions using a modified commercial perfusion system. Two whole livers were split into two left lateral segment grafts and two extended right grafts without interruption to blood flow and then perfused on separate machines. Not only does this provide the basis fo...