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HBPSurG 2024

Hybrid Meeting
Lyon, November 14-15, 2024
HBPSurG 2024
Rising Stars Awards
  • Gianluca Cassese
  • Cecilia Ferrari
  • Edoardo Maria Muttillo
  • Rithya Ou
  • Riccardo Pellegrini
  • Marta Rodrigo-Rodrigo
  • Juliette Cabot
Registration & Venue
Abstract Submissions Closed

It is our great pleasure to announce the 10th HBPSurG Meeting.

HBPSurG aims to gather experts in hepatobiliary & pancreatic diseases, surgery and oncology for an outstanding interdisciplinary scientific program, to contribute to the learning of young HBP specialists and trainees.

Experts will share their knowledge in the form of Keynote and State-of-the-art Lectures.

Looking forward to welcoming you.

Prof M Adham.

 
Meet the Experts :  Interactive Case Discussion
HBPSurG Invited Lectures
State-of-the-Art
Free papers

 

Meeting Program

Registration open all day

Prof M Adham

Chairs – L Milot, A Serrablo, F Rostain
  • 09h00-09h20 – Colorectal cancer with synchronous liver metastases. Dr K Horisberger (Mainz)
  • 09h20-09h40 – Liver mass. Prof A Serrablo (Zaragoza)
  • 09h40-10h00 – Bile duct stone. Prof A Çöker (Izmir)
  • 10h00-10h20 – Biliary stricture. Dr F Rostain (Lyon)
10h20-10h40 – Questions & Discussion
10h40-11h00 Coffee break
Chairs – JY Mabrut, G Nappo, F Panaro, J Perinel
  • 11h00-11h10 – Multi-visceral resection for left-sided pancreatic ductal adenocarcinoma: A multicenter retrospective analysis from European countries. Ferrari C et al.
  • 11h10-11h20 – Pancreatectomy with portal/mesenteric venous resection: a single center, high-volume experience integrating pancreatic surgery and liver transplantation. Pellegrini R et al.
  • 11h20-11h30 Early Immunoparalysis in Patients Undergoing Pancreaticoduodenectomy – An Exploratory Study based on mHLA-DR Expression. Ou R et al.
  • 11h30-11h40 – Transarterial radioembolization can downstage intermediate and advanced hepatocellular carcinoma to liver transplantation. Muttillo EM et al.
  • 11h40-11h50 – Laparoscopic versus open liver resection for huge hepatocellular carcinoma: a comprehensive analysis from a high-volume referral center. Cassese G et al.
  • 11h50-12h00 Predicting failure of curative possibilities in recurrent large hepartocellular carcinoma after resection: development & cross-validation of machine learning models.  Giannone F et al.
  • 12h00-12h10 Robotic left lateral sectionectomy in living donor liver transplantation (with video). Mabrut JY et al.
12h10-12h30 – Questions & Discussion
12h30-13h55 Lunch break

Split in-situ or ex-situ : Two Opposing or Complementary Strategies.

Prof JY Mabrut (Lyon)

Chair – Prof C Toso (Geneva)

Chairs – A Çöker, K Horisberger, JY Mabrut
  • 14h50-15h10 – Diagnostic imaging for liver malignancies. Dr R L’Huillier (Lyon)
  • 15h10-15h30 – Liver function assessment & patient selection. Prof C Toso (Geneva)
  • 15h30-15h50 – Electroporation for HBP malignancies. Prof L Milot (Lyon)
  • 15h50-16h10 – Robotic management of bile duct injuries. Prof  F Panaro (Montpellier)
16h10-16h30 Questions & Discussion
16h30-16h45 Break
Chairs – G Cassese, J Perinel, F Panaro

Registration open all day

Chairs – I Frigerio, S Gaujoux, B Napoleon
  • 08h30-08h50 – Pancreatic cystic lesion. Prof R Jorba Martin (Barcelona)
  • 08h50-09h10 – Post-pancreatectomy hemorrhage. Dr J Perinel (Lyon)
  • 09h10-09h30 – Post-operative pancreatic fistula. Dr G Nappo (Milano)
  • 09h30-09h50 – Pancreatic neuro-endocrine tumor. Dr A Durand (Lyon)
09h50-10h00 Questions & Discussion

Pancreatic Ductal Adenocarcinoma.

Prof K Conlon (Dublin)

Chair – Dr J Perinel (Lyon)

10h40-11h00 Coffee break
Chairs – K Conlon, R Jorba Martin, G Marchegiani
  • 11h00-11h20 – ISGPS definitions & standards of care. Prof G Marchegiani (Padova)
  • 11h20-11h40 – IPMN epidemiology, diagnosis & treatment. Dr I Frigerio (Pesceria del Garda)
  • 11h40-12h00 – Confocal microscopy in pancreatic cystic lesions. Dr B Napoleon (Lyon)
  • 12h00-12h20 – NF-PNET epidemiology, diagnosis & treatment. Prof S Gaujoux (Paris)
12h20-12h40 Questions & Discussion
12h45- 14h00 Lunch break
Chairs – G Cassese, EM Muttillo, G Nappo, J Perinel
  • 14h50-15h00 – Preliminary results of the multicenter, prospective randomized study that compares the efficacy and safety of outpatient medical treatment and home hospitalization vs. hospitalization of mild acute pancreatitis (PADI_2 Study). Rodrigo-Rodrigo M et al.
  • 15h00-15h10 –Patterns of site & timing of recurrence after curative resection in single & multiple large hepatocelluler carcinoma.  Giannone F et al.
  • 15h10-15h20 – Adaptation of antibiotics and anti fungal strategy to preoperative biliary drainage to improve postoperative outcomes after pancreatic resection.  Giannone F et al.
  • 15h20-15h30 – Prehabilitation in pancreatic surgery. Muttillo EM et al.
  • 15h30-15h40 – Bile Duct, Hepatic Artery and Portal Vein Injury During Laparoscopic Cholecystectomy. Choukr A et al.
  • 15h40-15h50 – IPMN & Polyostotic fibrous dysplasia. Cabot J et al.
Short Oral Posters
  • 15h50-15h55 – Primary Hepatic Neuroendocrine Tumor: A Case Report. Cuadrado-García A & al.
  • 15h55-16h00 – Modified technique of pancreatojejunostomy protection in patients operated on complicated forms of chronic pancreatitis. Punko Yuliia Anatoliivna & al.
16h00-16h20 Questions & Discussion

Authors & Institutions
Cecilia Ferrari MD (1, 2), Piera Leon MD (1), Massimo Falconi MD (3), Ugo Boggi MD (4), Tullio Piardi MD (5), Laurent Sulpice MD (6), Davide Cavaliere MD (7), Edoardo Rosso MD (8), Mircea Chirica MD (9), Ferruccio Ravazzoni MD (10), Riccardo Memeo MD (11), Patrick Pessaux MD (12), Vito De Blasi MD (13), Matteo Mascherini MD (2), Franco De Cian MD PhD (2), Francis Navarro MD (1), Fabrizio Panaro MD PhD

(1) University of Montpellier, HPB and Transplant Unit, Montpellier, France. (2) Ospedale Policlinico San Martino, Genova, Italy. (3) IRCCS Ospedale San Raffaele, Chirurgia Pancreatica, Milano, Italy. (4) Università degli Studi di Pisa, Ospedale Cisanello, Chirurgia HPB e Trapianto di Fegato, Pisa, Italy. (5) Reims University Hospital, Reims,

Background
Due to delayed diagnosis and a lower surgical indication rate, left-sided pancreatic ductal adenocarcinoma (PDAC) is often associated with a poor prognosis in comparison to pancreatic head tumors.
Multi-visceral resections (MVR) associated with distal pancreatectomy could be proposed for patients presenting with locally infiltrating disease.

Method
We retrospectively analyzed a multi-centric cohort of left-sided PDAC patients operated on from 2009 to 2020.  Thirteen European high-volume HPB centers participated in this study. We analyzed patients who underwent distal pancreatectomy (DP) associated with MVR and compared them to standard DP patients.

Results
Among 258 patients treated curatively for PDAC of the body and tail, 28 patients successfully underwent MVR. A longer operative time was observed in the MVR group (295 min +/- 74 vs. 250min +/- 96, p= 0.248). The post-operative complication rate was comparable between the two groups (46.4 % in MVR group vs. 62.2% in control group, p= 0.108). The incidence of positive margin (R1) was similar between the two groups (28.6% vs. 26.6%; p=0.827).
After a median follow-up of 25 (9-111) months, overall survival was comparable between the two groups (p= 0.519).

Conclusion
Multi-visceral resection in left-sided pancreatic ductal adenocarcinoma is safe and feasible and should be considered in selected cases as it seems to provide acceptable surgical and oncological outcomes.

Authors & Institutions
Pellegrini R. (1), Perri G. (2), Bassi D. (1), Serafini S. (1), Sperti C. (1), Gringeri E. (1), Cillo U. (1) and Marchegiani G. (1)

1- Hepato-pancreato-biliary and Liver Transplant Surgery Unit, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua (Padua, Italy). 2- Department of General Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Maggiore Hospital (Bologna, Italy)

Background
Pancreatectomy with portal (PV) and/or superior mesenteric vein (SMV) resection represents a delicate surgical procedure with different levels of complexity. The aim of this study is to evaluate the peri-operative outcomes and thrombosis risk among different PV-SMV resection types.

Method
All patients undergoing pancreatectomy with PV-SMV resection (according to ISGPS classification) between 2015-2023 at a single, high-volume hepato-bilio-pancreatic surgery & liver transplantation unit were retrospectively analyzed, including data on early (≤30 days) or late (≥1 year) PV-SMV thrombosis.

Results
Overall, 63 patients underwent PV-SMV resection: 40 (64%) tangential resections (TVR: ISGPS type 1-2) and 23 (36%) segmental resections (SVR: ISGPS type 3-4). Major complications (Clavien-Dindo ≥3a) were higher in SVR (57% vs 33%, p=0.07), while 30-days mortality didn’t differ (4% vs 7%, p=0.21). Most patients underwent anticoagulation with prophylactic heparin dosage (76%), while only 15 (24%) with therapeutic dosage (10/15 after SVR). Early (5% vs 13%, p=0.35) or late (5% vs 25%, p= 0.19) thrombosis rates didn’t differ, but ISGPS type 4 resections had the highest thrombosis risk (p=0.02).

Conclusion
Among PV-SMV resections, SVR are associated with a higher rate of major complications compared to TVR, but not mortality, while early and late thrombosis events were similar. Complex vein resections (ISGPS type 4) are safe in expert centers, but harbor increased risk of thrombosis.

Authors & Institutions
Edoardo Maria Muttillo, Giammauro Berardi, Nicola Guglielmo, Alessandro Cucchetti, Sofia Usai, Marco Colasanti, Roberto Meniconi, Stefano Ferretti, Germano Mariano, Marco Angrisani, Rosa Sciuto, Guido Ventroni, Pascale Riu, Valerio Giannelli, Adriano Pellicelli, Raffaella Lionetti, Giampiero D’Offizi, Giovanni Vennarecci, Roberto Cianni, Giuseppe Maria Ettorre

1 – Department of General, Hepatobiliary and Pancreatic Surgery, Liver Transplantation Service. San Camillo Forlanini Hospital
2 – “Department of Interventional Radiology: San Camillo Forlanini Hospital, Rome, Italy.
3 – “Nuclear Medicine Department, “S. Camillo-Forlanini” General Hospital,
4 – Department of Hepatology and Transplant Unit. San Camillo Forlanini, Rome, Italy

Background
Trans arterial radioembolization (TARE) is an effective locoregional therapy in patients with hepatocellular carcinoma (HCC) and its role in downstaging patients with advanced HCC to liver transplantation (LT) is still unclear. The aim of this study is to investigate the downstaging efficacy of TARE in patients with intermediate and advanced HCC from the locoregional procedure to LT

Method
Multistate modeling was performed. Patients moved through different health states from TARE to death. The following transitions were applied: 1) from TARE to listing, 2) from TARE to death without listing, 3) from listing to LT, 4) from listing to death without receiving LT, and 5) from transplant to death. Each transition was modeled using a flexible parametric survival analysis with 3 degrees of freedom. Factors affecting the chance of death after TARE were considered to stratify patients’ outcomes.

Results
214 patients underwent TARE. 43.9% had a radiological response and 29.9% were listed for LT. Finally, 49 patients (22.8%) were transplanted. One year after TARE, the probability of being alive without being listed or transplanted was 40.5% and significantly decreased at 5 years (11.2%). The chance of being listed was 9.4% at 1 year but dropped to 0.9% at 5 years. The probability of dying after TARE without receiving LT was 38% at 1 year and 73% at 5 years. The chance of being alive and having received a LT was 12.3%, 19.7%, and 15.1% at 1, 3, and 5 years respectively. Tumor burden outside the up-to-seven criteria, A F P > 4 0 0 n g / m L, and ALBI class 32 were associated with the transition from TARE to death. Median survival after TARE was 3.0 years for low-risk patients, 1.9 years for intermediate-risk, and 9 months for high-risk patients.

Conclusion
TARE is a safe and effective strategy for intermediate and advanced HCC with a 44% overall chance of inducing response, a 30% chance of downstaging patients within the transplant criteria, and a 23% probability of permitting LT.

Authors & Institutions
Rithya OU(1), Xavier Muller(1)(2), Kayvan Mohkam (1)(2), Jean-Yves Mabrut (1)(2), Mustapha Adham (3), Guillaume Monneret(4)(6), Thomas Rimmelé (4)(5).

(1) Croix-Rousse University Hospital, Department of General Surgery and Liver Transplantation, Lyon, France . (2) Hepatology Instituite Lyon, France. (3) Edouard Herriot University Hospital, Department of Digestive & HPB Surgery, Lyon, France. (4) EA 7426 “Pathophysiology of Injury-Induced Immunosuppression”, Joint Research Unit HCL bioMérieux, Univeristé Lyon 1, Lyon, France. (5) Edouard Herriot University Hospital, Anesthesiology and Critical Care Medicine, Lyon, France. (6)Edouard Herriot University Hospital, Immunology Laboratory, Lyon, France

Background
This study aims to evaluate the postoperative immune response of patients undergoing pancreaticoduodenectomy (PD) based on monocytic HLA-DR (mHLA-DR) expression and investigate its association with postoperative pancreatic complications.

Method
This is an ad-hoc analysis of the REALISM study focusing on all patients who underwent elective PD between 2016 to 2017 and had routine monocytic HLA-DR (mHLA-DR) expression measurement. In detail, mHLA-DR measurments were performed at postoperative days (POD) 0, 1, 3-4, 5-7, 14, 28 and 60. In addition, pancreatic related complications including clinically relevant pancreatic fistula (CR-POPF) and postpancreatectomy acute pancreatitis (PPAP) were assessed.

Results
A total of 24 patients were included. The expression of mHLA-DR decreased in all patients during the postoperative course and reached its lowest level between POD 1 and 3. In patients presenting with a CR-POPF, mHLA-DR levels were significantly lower at POD 1 (4,711 Ab/C vs 10,885 Ab/C, P = 0,005) and stayed at lower levels during the first postoperative week. Patients presenting with CR-PPAP had also lower mHLA-DR levels compared to those without pancreatic related complications with the lowest levels at POD 3 (4,621 Ab/C vs 7,660 Ab/C, P = 0,004).

Conclusion
Patients undergoing PD present an early and persisting postoperative immunoanergy. The latter is more pronounced in patients with pancreatic related complications as show by low HLA-DR expression as early as POD 1.

Authors & Institutions
Gianluca CASSESE 1,2, Ho-Seong HAN 2, Boram LEE 2, Hae Won LEE 2, Jai Young CHO2

1 – Department of Clinical Medicine and Surgery, Division of HBP Minimally Invasive and Robotic Surgery. Transplantation Service, Federico II University Hospital, Naples, Italy. 2 – Department of HPB Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea

Background
There is still poor evidence about the safety and feasibility of laparoscopic liver resection (LLR) for huge (>10cm) hepatocellular carcinomas (HCC). The aim of this study was to assess the short- and long- term outcomes of LLR versus open liver resection (OLR) for patients with huge HCC from real life data from consecutive patients.

Method
Data regarding all consecutive patients undergoing liver resection for huge HCC were retrospectively collected from a Korean referral HPB center. Primary outcomes were the postoperative results, while secondary outcomes were the oncologic survivals.

Results
Sixty-three patients were included in the study: 46 undergoing OLR and 17 LLR, with no significant differences in all preoperative characteristics. There were no statistically significant differences in estimated blood loss, operation time, transfusions, postoperative bile leak, ascites, severe complications and R1 resection rates. After a median follow-up of 48.4 (95% CI: 8.9-86.8) months, there were no statistically significant differences in 3-years and 5-years OS (p = 0.10), as well as in both 3-years and 5-years DFS (p = 0.13).

Conclusion
Laparoscopic liver resection for giant tumors (larger than 10 cm) can be safely performed in selected cases in referral centers, without affecting both perioperative and long-term outcomes.

Authors & Institutions
Marta Rodrigo-Rodrigo (1), Elena Ramírez-Maldonado (1), Sandra Lopez Gordo (2), Rui Pedro Major Branco (3), Daniel Coronado Llanos (4), Guillem Soy (5), Rosa Jorba-Martin(1)

1. University Hospital Joan XXIII Tarragona, Spain, 2. Consorci General del Maresme, Mataró, Spain, 3. Hospital Gracia de Orta, Almada, Portugal, 4. Moises Broggi Hospital, Sant Joan Despí, Spain, 5. Clínic Hospital, Barcelona, Spain

Background
In 2019, with the results of the PADI_1 study, we implemented the early start of diet in the emergency room, for mild and moderate cases of AP, which resulted in a reduction in length of stay and hospital costs, without an increase in readmission rates, complications or mortality. Now, we proposed a new study that aims to determine if home treatment has the same results as hospital treatment.

Method
A preliminary analysis is carried out on 50% of the data from the prospective, multicenter study, PADI_2 (NCT05360797), of patients with mild AP randomized into 3 treatment arms (outpatient, home hospitalization, and hospital admission) between April 2022 and January 2024. Variables such as diet tolerance, pain control, pain relapse or severity, length of stay, hospital costs, 30-day readmissions, complications, and patients’ perception of safety/satisfaction were evaluated.

Results
We analyzed the data of 105 patients from 5 hospital centers, who presented a mild form of the disease. Average age 56 years, 62% women, 78% of biliary origin. There are no significant differences in diet tolerance (p=0.87), pain control (p=091), pain relapse or severity (p=0.08), hospital readmission (p=0.71), complications (p=0.47), patient satisfaction and safety (p=1.00). Significant differences are found in hospital stay (p<0.0001) and hospital costs.

Conclusion
This preliminary evaluation indicates that patients with mild AP achieve comparable clinical outcomes, with positive patient satisfaction and a significant reduction in hospital costs when opting for home medical treatment (outpatient care or home hospitalization).

Authors & Institutions
Jean-Yves Mabrut MD PhD 1,2, Xavier Muller MD PhD1,2, Guillaume Rossignol MD1,2, Kayvan Mohkam MD PhD 1,2

1 Department of General Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France. 2 Lyon Hepatology Institute, INSERM U1052, Lyon, France.

Background

The laparoscopic approach for living donor left lateral sectionectomy is now well standardized (1). Given the recent developments of robotic-assisted liver surgery, this technology may also benefit the field of liver transplantation (2-3). In this report, we provide a step-by-step description of our technique for robotic-assisted living donor left lateral sectionectomy.

Method

The patient is positioned in a supine position with a 10-15° reverse Trendelenburg position and 5-10° left tilt (Fig 1). The intervention is carried out according to the following steps:

– Mobilization of the left lateral lobe with identification of the distal part of the left hepatic vein (LHV).

– Selective dissection of the left border of the liver hilum after identification of a potential accessory left hepatic artery in the lesser omentum. The left branch of the portal vein is dissected and its branches for segment 4 +/- 1 are divided.

– Parenchymal transection is carried out using 2 bipolar coagulation forceps. The transection is started at the right border of the falciform ligament after ultrasound control to identify a potential scissural vein. No routine pedicle clamping is performed. The S4 portal pedicle is identified and divided allowing to expose the umbilical plate within the parenchyma.

– Section of the left hepatic duct (Fig 2) using robotic scissors, followed by a selective running suture of the stump of the left hepatic duct.

– Dissection of the distal part of the LHV (Fig 3).  After separation of the left lateral lobe from segment 1, the dissection of the LHV is completed.

– Positioning of the graft in an extraction bag introduced through a 10 cm suprapubic incision.

– Selective vascular divisions:  The left hepatic artery and portal vein are divided after application of Hem-o-lok© clips. LHV is divided using a vascular stapler.

– Extraction of the graft trough the previously performed suprapubic laparotomy followed by graft flushing on the back-table.

– Omentoplasty of the liver transection surface without intrabdominal drainage followed by abdominal wall closure (Fig 4).

Conclusion

The robotic-assisted living donor left lateral sectionectomy reported in this video follows the same steps previously established in laparoscopic liver surgery. Owing to the stability and magnification of the 3Dl view, the robotic approach allows for more precise vascular dissection and facilitates the section of the left hepatic duct. However, a careful handling of the robotic instruments is necessary to prevent tissue trauma given the lack of haptic feedback.

Authors & Institutions
Zainab El Zein (1), Luna Choukr(2), Ali Choukr (1)
1- Lebanese University Faculty Of Medical Sciences. 2- Saint-Joseph University, Faculty of Medicine

Background
We present a case of a 52-year-old man who sustained an injury to his bile ducts, his right hepatic artery, and his right portal vein, during an elective laparoscopic cholecystectomy, That was managed in our University Hospital

Method
The case presented to us one week after a laparoscopic cholecystectomy after which the patient was discharged the following day, at presentation he was septic, jaundiced and coagulopathic.
After resuscitation the imaging showed: a right hepatic artery complete obstruction, a right anterior portal branch thrombosis, a complete necrosis of the right anterior liver sector, and a high bile duct injury on the Hilar plate and a perihepatic bile collection, with a right pleural reactional effusion.

Results
After resuscitation, The patient was taken to Surgery and had a peritoneal lavage an an external biliary drainage to control his episode of sepsis, the Bilirubin was too high to perform a liver resection in that setting,  After 10 days in the ICU , the patient condition and the liver function allowed us to perform the definitive treatment: he underwent a right hepatectomy with a  right portal thrombectomy, and a Roux en Y Hepatico jejunostomy on the Left Duct. the post op course was smooth , and the follow up labs and CT at one month were very satisfactory,

Conclusion
In complex Vasculobiliary Injuries post cholecystectomy The delay of the repair especially after the control of sepsis,  has a lower risk of hepatectomy and shows the true demarcation  line of  the ischemic Bile ducts for the biliary repair,

Authors & Institutions
Fabio Giannone, Gianluca Cassese, Antonio Cubisino, Emanuele Felli, Federica Cipriani, Bruno Branciforte, Rami Rhaiem, Alessandro Tropea, Edoardo Maria Muttillo, Andrea Scarinci, Bader Al Taweel, Raffaele Brustia, Ephrem Salame, Daniele Sommacale, Salvatore Gruttadauria, Tullio Piardi, Gian Luca Grazi, Guido Torzilli, Luca Aldrighetti, Mickael Lesurtel, Ho-Seong Han, Fabrizio Panaro, Patrick Pessaux

a Hepato-Pancreato-Biliary, Oncologic and Robotic Unit, Azienda Ospedaliero-Universitaria SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
b Robotic and HPB Research Unit, Research and Innovation Department (DAIRI), Azienda Ospedaliero-Universitaria SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
c Department of Visceral and Digestive Surgery, University Hospital of Strasbourg, Strasbourg, France
d Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic Hepato-Pancreato-Biliary Surgery, and Transplantation Service, Federico II University Hospital, Naples, Italy
e Department of Surgery, Division of Hepato-Pancreato-Biliary Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
f Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University of Paris Cité, Clichy, France
g Liver Transplant and Surgery Department, Trousseau Hospital, Tours, France
h Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
i Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, Humanitas Clinical and Research Center – IRCCS, Rozzano, Milan, Italy
j Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
k Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT, UPMC (University of Poittsburgh Medical Center), Palermo, Italy
l Surgical and Medical Department of Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
m Department of Surgery, Division of HBP Surgery and Transplantation, Saint-Eloi Hospital, University Hospital of Montpellier, Montpellier, France
n Department of Digestive and Hepato-pancreatic-biliary Surgery, AP-HP, Hôpital Henri-Mondor, Paris Est Créteil University, UPEC, Créteil, France and Team “Pathophysiology and Therapy of Chronic Viral Hepatitis and Related Cancers”, INSERM U955, Créteil, France
o Department of Surgery and Medical and Surgical Specialties, University of Catania, Catania, Italy
p Chirurgia Epatobiliopancreatica, AOU Careggi, Florence, Italy
q Université de Strasbourg, Inserm, Institut de Recherche sur les Maladies Virales et Hépatiques, U1110, Strasbourg, France 

Background
Curative options for large Hepatocellular carcinoma (LHCC) are limited because of the high risk of early and extrahepatic recurrence, which are associated with impaired outcomes. However, only a few studies report data on outcomes in resected LHCC. In this study, we therefore investigated timing and site of recurrence in these patients and assessed factors strictly associated with these patterns.

Method
This is a retrospective study conducted on a multicentric database provided by twelve hepato-biliary high-volume centers. Only surgical cases presenting an histo-pathologically confirmed HCC, with a tumor diameter > or = 5 cm at preoperative imaging, considered resectable at diagnosis and undergoing an anatomical hepatic resection with a curative intent between January 2014 and December 2021 were included. Extrahepatic recurrence was defined as the appearance of any distant site of metastasis, while recurrence within two years after surgical resection was classified as early recurrence.

Results
A total of 869 patients were included. Recurrence was observed in 487 (56%) resected cases. Patterns associated with impaired outcomes were early (p <0.001) and simultaneous intrahepatic and extrahepatic recurrence (p= 0.038). Variables independently associated with early recurrence were age (p= 0.037), major hepatectomy (p= 0.023), MVI (p= 0.011), satellites nodules (p= 0.005) and open approach (p= 0.025). Variables correlated with simultaneous intra and extrahepatic relapse were age (p <0.001), preoperative TACE (p <0.001), microvascular invasion (p <0.001) and satellite nodules (p= 0.026).

Conclusion
SR for LHCC is associated with a high risk of early recurrence, which are cases patients with a higher burden of disease. Apart from pathological variables, factors independently associated with worse patterns were open approach and use of preoperative TACE.

Authors & Institutions
Fabio Giannone, Emanuele Felli, Antonio Cubisino, Federica Cipriani, Bruno Branciforte, Rami Rhaiem, Alessandro Tropea, Edoardo Maria Muttillo, Andrea Scarinci, Bader Al Taweel, Raffaele Brustia, Ephrem Salame, Daniele Sommacale, Salvatore Gruttadauria, Tullio Piardi, Gian Luca Grazi, Guido Torzilli, Luca Aldrighetti, Mickael Lesurtel, Fabrizio Panaro, Patrick Pessaux

a Hepato-Pancreato-Biliary, Oncologic and Robotic Unit, Azienda Ospedaliero-Universitaria SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
b Robotic and HPB Research Unit, Research and Innovation Department (DAIRI), Azienda Ospedaliero-Universitaria SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
c Department of Visceral and Digestive Surgery, University Hospital of Strasbourg, Strasbourg, France
f Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University of Paris Cité, Clichy, France
g Liver Transplant and Surgery Department, Trousseau Hospital, Tours, France
h Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
i Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, Humanitas Clinical and Research Center – IRCCS, Rozzano, Milan, Italy
j Department of Oncological Digestive Surgery, Hepatobiliary and Pancreatic Surgery Unit, University Reims Champagne-Ardenne, Reims, France
k Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT, UPMC (University of Poittsburgh Medical Center), Palermo, Italy
l Surgical and Medical Department of Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
m Department of Surgery, Division of HBP Surgery and Transplantation, Saint-Eloi Hospital, University Hospital of Montpellier, Montpellier, France
n Department of Digestive and Hepato-pancreatic-biliary Surgery, AP-HP, Hôpital Henri-Mondor, Paris Est Créteil University, UPEC, Créteil, France and Team “Pathophysiology and Therapy of Chronic Viral Hepatitis and Related Cancers”, INSERM U955, Créteil, France
o Department of Surgery and Medical and Surgical Specialties, University of Catania, Catania, Italy
p Chirurgia Epatobiliopancreatica, AOU Careggi, Florence, Italy
q Université de Strasbourg, Inserm, Institut de Recherche sur les Maladies Virales et Hépatiques, U1110, Strasbourg, France 

Background
Large hepatocellular carcinoma (LHCC) are lesions with a diameter >5 cm characterized by an adverse outcome and by a limited therapeutic armamentarium. While different models exists to predict aggressive tumors in small HCC, for LHCC are lacking. We therefore aim to create a pre- and post-operative model to predict tumors whose pattern of recurrence will lead the patient to a palliative treatment.

Method
This is a retrospective study conducted on a multicentric database provided by eleven hepato-biliary high-volume centers. LHCC undergoing an hepatic resection with a curative intent between January 2014 and December 2021 were included. Data on outcomes were assessed, combined with type of treatment allocation and categorized as: no recurrence, curative treatment, local palliative treatment, and systemic palliative treatment/best supportive care (BSC). Pre- and post-operative models were evaluated through Area Under Curve (AUC), with Hand and Till adaptation for multinomial prediction.

Results
The cohort included 633 patients, of which 292 (46%) without recurrence, 92 (15%) receiving a curative treatment, 93 (15%) undergoing a local palliative treatment and 156 (25%) needing a systemic treatment/BSC. Preoperative models yielded an AUC of 0.59 and 0.61, with sensitivities ranging from 0.91 for no relapse to 0.01 for local palliative treatment. Postoperative model using random forest yielded an AUC of 0.68 and 0.64, with sensitivities ranging from 0.92 for no recurrence to 0.05 to local palliative treatment.

Conclusion
This represents the first attempt to predict curative possibilities in recurrent LHCC after resection, with the aim of improving treatment flow-chart in these tumors. Although AUCs obtained are satisfactory, sensitivities are low for some classes, limiting the applications in clinical practice.

Authors & Institutions
Fabio Giannone MD,1,2 Charles Lagarrigue MD,3 Oronzo Ligurgo MD,1 Lina Jazaerli MD,3 Paul Michel Mertes MD, PhD,3 Oliver Collange MD, PhD,3 Patrick Pessaux MD, PhD1,2

1 Department of Visceral and Digestive Surgery, University Hospital of Strasbourg, Strasbourg, France. 2 Strasbourg University, Inserm, Institut de Recherche sur les Maladies Virales et Hépatiques, U1110, Strasbourg, France. 3 Department of Anesthesiology and Intensive Care, University Hospital of Strasbourg, Strasbourg, France.

Background
Biliary contamination significantly correlates with major comorbidities during pancreatic head resection. Recently, a piperacillin-tazobactam prophylaxis demonstrated a lower rate of infectious complications (IC) and post-operative pancreatic fistula (POPF). However, patients without a preoperative biliary drainage (PBD) probably don’t benefit from this antibiotic due to the low contamination rate

Method
All retrospective cases undergoing pancreatic head resection with intraoperative biliary sample were included. Post-operative outcomes of patients with a piperacillin-tazobactam-based treatment were compared to cases in which a narrow-spectrum antibiotic was administrated, stratified according to the use of a PBD. The same analysis was repeated for antifungal treatment administration.

Results
Among the 205 cases included, PBD was necessary in 127 patients (62%). Broad-spectrum treatment was associated with fewer overall and clinically relevant POPF (p=0.001 and p=0.004), overall morbidity (p=0.044) and overall IC (p=0.018), but only in the PBD group. Similarly, antifungal treatment was significantly associated with some specific IC only in the PBD group. At multivariate analysis, antifungal therapy in the whole cohort (p=0.029) and the use of a piperacillin-tazobactam (p=0.007) treatment in patients with a PBD were independently associated with clinically-relevant POPF.

Conclusion
A  broad-spectrum antibiotic administration should be limited to cases in which a PBD was previously positioned. Furthermore, the use of an antifungal prophylaxis or therapy should be further investigated in these patients because it may reduce the risk of some IC.

Authors & Institutions
Cuadrado-García A1, Fernández R1, Ortega I1, Gonzalez M1, Rodriguez Carrillo JL2, Muñoz Fernandez de Legaria M 2, Cuadrado-Torres A3,Hernandez M 1, Mellado I1,   Gajda J1, Peck C1, Picardo AL1

1 Servicio de Cirugía General y Digestiva. 2 Servicio de Anatomía Patolológica Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid. Universidad Europea de Madrid. 3 Universidad Autónoma Barcelona

Background
Neuroendocrine tumors (NETs) are rare tumors that arise from cells of the neuroendocrine system.Primary hepatic neuroendocrine tumors (PHNETs) are extremely rare, accounting for only 0.46% of all primary hepatic tumors. They occur predominantly in adults and  in the right hepatic lobe.  Diagnosis can be challenging due to their non-specific radiographic features.

Method
Case Presentation:
A 37-year-old male patient presented with jaundice, fatigue, generalized pruritus, abdominal pain, and weight loss.
Laboratory tests, imaging studies, and a biopsy were performed.
The final diagnosis was a 29 mm well-differentiated PHNET.
Surgical Treatment: An uneventful extended right hepatectomy was performed.

Results
The clinical, pathological, and therapeutic features of PHNETs are discussed.
The importance of surgical resection as the treatment of choice is highlighted.
Other therapeutic options such as chemotherapy, radiotherapy, and targeted therapy are mentioned.

Limitations:
This is a single case report and the findings may not be generalizable to all patients with PHNETs.

Recommendations:
Further studies with larger patient numbers are needed to confirm the findings of this case and to develop better diagnostic and treatment strategies for PHNETs.

Conclusion
PHNETs are rare tumors with nonspecific symptoms.
Diagnosis requires a comprehensive serological, radiological, and immunohistochemical evaluation.
Surgical resection is the treatment of choice.
More studies are needed to improve the diagnosis and treatment of PHNETs.

Authors & Institutions
1. Kanikovskyi Oleh Evheniyovych, Head of Department of Surgery of Medicine faculty №2, National Pirogov Memorial Medical University, Vinnytsia. 2. Pavlyk Ihor Vasylovych, Associate Professor of Department of Surgery of Medicine faculty №2, National Pirogov Memorial Medical University, Vinnytsia, Ukraine. 3. Punko Yuliia Anatoliivna, PhD Student of Department of Surgery of Medicine faculty №2, National Pirogov Memorial Medical University, Vinnytsia, Ukraine

Background
Assessing the efficiency of managing posoperative complications, one of them like pancreatorrhagia, in patients who underwent surgery for complicated chronic pancreatitis by safeguarding pancreatojejunostomy through jejunostomy.

Method
Among 257 patients who underwent surgery for complicated chronic pancreatitis at the Surgical Clinic of Department of Surgery, Medical Faculty №2, National Pirogov Memorial Medical University, Vinnytsia, between 2000 and 2024, 8 patients (3,11%) experienced pancreatorrhagia in the postoperative period. Surgical intervention in these patients involved pancreatojejunostomy followed by jejunostomy for protection the anastomosis.

Results
A method has been devised for creating a longitudinal pancreatojejunostomy on an isolated Roux loop, followed by Braun’s anastomosis and the subsequent establishment of pancreatojejunostomy protection using an enterostomy. This approach enables monitoring the onset of initial pancreatorrhagia symptoms in the early and late postoperative period in patients who were undergoing surgery for complicated forms of chronic pancreatitis, with the ability to prevent the occurrence of pancreatorrhagia.

Conclusion
Protecting the pancreatojejunostomy with an enterostomy in patients undergoing surgery for complicated chronic pancreatitis enables the management of pancreatorrhagia, allowing for the cessation of bleeding through conservative measures without the need for additional surgical procedures

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