*Purpose: Colorectal cancer is the third leading cause of cancer related death, and 50% of patients will either present with synchronous or develop colorectal liver metastases (CRLM). Unfortunately, only 30% of patients with CRLM and no evidence of extrahepatic disease are able to undergo primary resection due to multifocality of disease. Despite recent advances combination targeted and chemotherapies, best 5-year survival for liver-confined CRLM remains at best 20%. Recent Norwegian trials (SECA I and II) have demonstrated 5-year overall survival which eclipse 80% in strictly selected cohorts. Here we present a North American experience in applying hepatectomy and living-donor right split transplantation (LD-LTX) for CRLM.

*Methods: Prior to initiation of institutional protocol, a multidisciplinary team of radiologists, medical oncologists, surgical oncologists, transplant gastroenterologists and transplant surgeons reviewed available European experience and developed strict criteria for evaluating liver-confined unresectable CRLM for consideration of LD-LTX. Patient and donor clinicopathologic data was prospectively collected following informed consent for inclusion into the institutional registry.

*Results: Following a multidisciplinary taskforce, the institution adopted the OSLO criteria: No more than three of the following: tumor diameter > 5.5cm, CEA >80ug/L, < 2 years from diagnosis to transplantation, disease progression on systemic therapy, and additionally patients were excluded with combination mutations of KRAS and TP53. The protocol was initiated in June of 2019 with initial evaluation of 10 candidate patients, per protocol, a response and primary control must be demonstrated for continuation of consideration. 8/10 patients demonstrated disease progression and were referred for palliative chemotherapy. 2/10 met Oslo criteria, and underwent LD-LTX. Postoperatively, one patient was discharged without complication and the second patient experienced a bile leak requiring percutaneous drainage (Clavien-Dindo 3a). Both patients have no evidence of recurrent disease through short-term follow up. Both living donors had an uneventful postoperative course without complication.

*Conclusions: To date, our experience is rapidly evolving with LD-LTX for CRLM, however a clear finding is the relatively high rate (80%) of drop out from presentation to LT utilizing strict selection criteria.

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