RAPID (Resection And Partial Liver Transplantation With Delayed Total Hepatectomy) is a novel two-stage surgical procedure, with only 23 reported cases, involving partial liver resection and transplantation of a left lobe (stage 1) followed by a delayed total hepatectomy (stage 2). The perioperative anesthetic management of these recipients presents unique challenges and has never been described so far.

We report on ten patients with unresectable liver metastases who underwent this procedure from a living donor in our center between May 2020 and April 2024. Retrospectively, we collected preoperative, graft-related, and intraoperative management data during stage 1 (S1) and stage 2 (S2), and postoperative outcomes.

Recipients’ median age was 53 (50–57), median graft-to-recipient weight ratio 0.43 % (0.41–0.45), total ischemia time 82 min (75–105). No patients experienced postreperfusion syndrome. Median intensive care unit (ICU) stay was 36 h (27–48) after S1, 24 h (24–48) after S2. Median INR on POD 3 was 1.20 (1.13–1.29) after S1, 1.29 (1.16–1.70) after S2. Complications after S1 included portal thrombosis in one patient, and three required revision surgery. After S2, one patient required revision for hemostasis, and another developed acute kidney injury. This patient died on day 12 from bleeding post-thoracocentesis for pleural effusion. Six-month survival rate was 90 %.

These preliminary data, as a first step in developing perioperative management protocols for this innovative surgery, show good hemodynamic tolerance, no postreperfusion syndrome, and preserved liver function throughout the process. These results highlight the RAPID procedure's safety during surgery and postoperative course.