Abstract Book
HBPSurG 2024
Multi-visceral resection for left-sided pancreatic ductal adenocarcinoma: A multicenter retrospective analysis from European countries.
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.
Pancreatectomy with portal/mesenteric venous resection: a single center, high-volume experience integrating pancreatic surgery and liver transplantation.
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.
Transarterial radioembolization can downstage intermediate and advanced hepatocellular carcinoma to liver transplantation.
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.
Early Immunoparalysis in Patients Undergoing Pancreaticoduodenectomy – An Exploratory Study based on mHLA-DR Expression.
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.
Laparoscopic versus open liver resection for huge hepatocellular carcinoma: a comprehensive analysis from a high-volume referral center.
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.
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).
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).
Robotic left lateral sectionectomy in living donor liver transplantation (with video).
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.
Bile Duct, Hepatic Artery and Portal Vein Injury During Laparoscopic Cholecystectomy.
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,
Patterns of site & timing of recurrence after curative resection in single & multiple large hepatocelluler carcinoma.
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.
Predicting failure of curative possibilities in recurrent large hepartocellular carcinoma after resection: development & cross-validation of machine learning models.
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.
Adaptation of antibiotics and anti fungal strategy to preoperative biliary drainage to improve postoperative outcomes after pancreatic resection.
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.
Primary Hepatic Neuroendocrine Tumor: A Case Report.
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.
Modified technique of pancreatojejunostomy protection in patients operated on complicated forms of chronic pancreatitis.
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
HBPSurG 2025
The impact of tumor burden score on postoperative morbidity and survival in colorectal cancer patients with liver metastases
Authors & Institutions
Anton Burlaka, Volodymyr Bezverhnyi, Veronika Rozhkova, Vitalii Zvirych, Andriy Beznosenko, Serhii Zemskov
National Cancer Institute, Kyiv, Ukraine. O. Bogomolets National Medical University, Kyiv, Ukraine.
Background
Introduction. Surgical oncologists are increasingly interested in how to make the transition from technically to biologically guided surgery for colorectal cancer with liver metastases (mCRC). Taking into account the tumor burden score (TBS) has demonstrated its effectiveness and accuracy in predicting the risk of cancer-specific death in a number of studies.
Method
A retrospective analysis of patients with mCRC who underwent liver resection in the period from September 2002 to March 2024 at the clinic of the National Cancer Institute was performed. The selected cohort included 351 patients with synchronous and metachronous metastatic liver disease (cT1-4N0-2M0-1).
The tumor burden index was used as a combined indicator of the TBS, taking into account the maximum size of the metastasis and the number of foci was calculated according to the Sasaki et al. “Metro-ticket” mathematic model.
Results
The median and 5-year OS in these cohorts were 69.5 months, 60.3 months, and 23.1 months, and 56.3%. 49.7% and 7.4%, respectively (p<0.001).
The ability of the TBS to predict postoperative complications was analyzed using the ROC curve, which demonstrated high sensitivity with AUC = 0.822.
According to multivariate Cox analysis, TBS clusters had a significant negative impact on overall survival, in particular, cohorts with TBS 3.5-10 (HR: 0.43, 95% CI: 0.18 – 0.97, P = 0.04) and TBS ≥10 (HR: 1.4, 95% CI: 1.31 – 1.46, P = 0.005).
Conclusion
This study demonstrated that the tumor burden score can be applied to patients to national population-based cohort of colorectal cancer patients with liver metastases. The tumor burden score has a strong prognostic potential for overall survival and surgical complications.
Liver surgery legitimacy in patients with multiple liver metastasis: retrospective analysis
Authors & Institutions
Anton Burlaka(1,2), Serhii Zemskov(2), Volodymyr Skyba (2).
1 – Hepatopancreatobiliary Department of National Cancer Institute, Kyiv, Ukraine
2 – Bogomolets National Medical University National Medical University, Kyiv, Ukraine
Background
The aim of this study was to determine the oncologic feasibility of surgical treatment of patients with CRC with multiple metastases using the tumor burden score (TBS) in a Ukrainian population-based cohort.
Method
Five hundred twenty-one consecutive patients who underwent liver resections for CRC LM between January 2002 and January 2024 were identified from the National cancer institute (Kyiv, Ukraine) prospective database and analysed retrospectively.
Results
The median and 5-year overall survival in cohorts with TBS clusters ≤3, ≥3-9 and >9 was 116.2 months, 50.3 months and 29.7 months; and 75.7%, 42.4% and 41.6%, respectively (р<0.001). TBS index has been shown the high postoperative morbidity prognostic specificity and sensitivity with AUC 0.97 on the ROC curve. The multivariate Cox regression model has shown the TBS clusters had a significant negative impact on overall survival, in particular, cohorts with TBS ≥3-9 (HR: 0.43, 95% CI: 0.18 – 0.97, P = 0.04) and TBS ≥9 (HR: 1.4, 95% CI: 1.31 – 1.46, P = 0.005).
Conclusion
This study demonstrates the rationality of surgical treatment of patients with multiple bilobar colorectal cancer liver metastases in Ukrainian population-based cohort.
Comparative effectiveness of immune-targeted and interventional therapies in HCV/HBV-infected vs non-infected patients
Authors & Institutions
Saud Ahmad Saad – West China Hospital, Sichuan University
Background
To evaluate differences in treatment response and outcomes between HBV/HCV-infected and non-infected HCC patients receiving immune-targeted therapies and hepatic artery infusion chemotherapy (HAIC).
Method
We retrospectively analyzed 80 HCC patients divided into HBV/HCV-infected (n=40) and non-infected (n=40) groups. All patients received either immune checkpoint inhibitors plus targeted therapy or HAIC-based combinations. Primary endpoints were overall response rate (ORR), progression-free survival (PFS), and overall survival (OS), assessed across groups.
Results
Non-infected patients had a higher ORR (55%) than HBV/HCV-infected patients (42.5%). HAIC-based therapies showed greater PFS benefits in the infected group. Median OS favored non-infected patients overall, but outcomes were more comparable in the subgroup receiving both HAIC and immunotherapy.
Conclusion
HBV/HCV status influences response to immune-targeted and interventional therapies in HCC. Viral etiology should be considered when selecting treatment, and further prospective studies are needed to optimize strategies.
Optimizing Surgical Management in High-Risk Pancreatic Resections: Comparative Outcomes of Duct-to-Mucosa and Blumgart Pancreaticojejunostomy Versus Total Pancreatectomy for Postoperative Fistula Prevention
Authors & Institutions
Evgenia Charitaki1, Charina Triantopoulou2, Eva Mastrokosta3, Hara Nikolaou4, Vasiliki Kuriakou1, Vasilis Karambas1, Nikos Kokoroskos1, Miltiadis Papastamatiou1, Spiros Delis1
1. Konstantopouleio General Hospital, Surgical Department, Athens, Greece.
2. Konstantopouleio General Hospital, Radiology Department, Athens, Greece.
3. Konstantopouleio General Hospital, Anesthesiology Department, Athens, Greece.
4. Konstantopouleio General Hospital, ICU, Athens, Greece.
Background
Given the high morbidity associated with postoperative pancreatic fistula following pancreaticoduodenectomy, this study aims to compare surgical outcomes between duct-to-mucosa and Blumgart pancreaticojejunostomy, and to evaluate total pancreatectomy as a risk-adapted approach in high-risk cases.
Method
We retrospectively analyzed 60 patients undergoing pancreaticojejunostomy (30 DM, 30 BT) and 34 undergoing total pancreatectomy. All had soft pancreatic parenchyma, ducts <3 mm, and periampullary malignancies. Primary endpoints included POPF, DGE, and postoperative hemorrhage. Secondary measures were operative time and hospital stay. Outcomes were assessed to identify optimal strategies for high-risk cases.
Results
POPF occurred in 26% of DM cases and 10% of BT cases, with only grade A fistulas in BT. DGE was more common in DM (33%) than BT (10%). BT was associated with shorter operative time and median hospital stay (10 vs. 18 days). In the PD vs. TP cohort, 32 PD patients developed POPF; none occurred in TP. DGE was 29% in PD and 12% in TP. No postoperative hemorrhage was observed. TP had shorter hospital stay (6 vs. 10 days) with similar operative time.
Conclusion
Blumgart anastomosis showed superior outcomes over duct-to-mucosa in soft pancreas. Total pancreatectomy eliminated POPF and reduced morbidity and hospitalization in selected high-risk patients, despite endocrine and exocrine insufficiency. Technique selection should be risk-adapted.
Impact of ERAS Compliance on Postoperative Outcomes and Hospital Stay in Liver Surgery
Authors & Institutions
Nottberg, Valerie Isabel (1); Nottberg, Eleanor (1,2); van Rüth, Victoria (1); Brodersen, Freya (1); Ghadban, Tarik (1); Hackert, Thilo (1); Izbicki, Jakob (1); Heumann, Asmus (1).
(1) Department of General, Visceral, and Thoracic Surgery; University Medical Center Hamburg-Eppendorf
(2) Department of Urology; Medical Faculty and University Hospital Düsseldorf
Background
Enhanced Recovery After Surgery (ERAS) protocols aim to improve surgical outcomes through standardized perioperative care. However, the relative influence of individual ERAS components remains unclear. This study evaluates which ERAS factors significantly affect postoperative complications, morbidity, and hospital length of stay in patients undergoing liver surgery.
Method
A total of 637 patients who underwent liver surgery at the University Medical Center Hamburg-Eppendorf between January 2020 and December 2024 were retrospectively analyzed. Data were collected through the ERAS Interactive Audit System (EIAS). Perioperative compliance was calculated for each patient, and patients were stratified into high compliance (≥70%) and low/moderate compliance (<70%) groups.
Statistical analyses were performed in R Studio. Univariate analyses included Chi-square tests for categorical outcomes (e.g., complications, morbidity) and Welch’s t-tests for continuous variables (e.g., blood loss, operation duration). Odds ratios (OR) with 95% confidence intervals (CI) were calculated to estimate the association between compliance and outcomes. Subsequently, multivariate logistic and linear regression models were used to adjust for potential confounders.
Results
High perioperative compliance was associated with significantly fewer postoperative complications during the primary hospital stay (51.0% vs. 69.8%, p < 0.001; OR = 0.45, 95% CI: 0.30–0.67) and lower severe morbidity rates (Clavien-Dindo > IIIb: 87.2% vs. 96.4%, p = 0.002; OR = 0.25, 95% CI: 0.10–0.64). Additionally, patients in the high compliance group had a significantly shorter hospital stay (7.4 vs. 10.6 days; difference: −3.2 days, 95% CI: −4.7 to −1.7; p < 0.001).
In multivariate analyses, minimally invasive surgery and early mobilisation on the day of surgery were protective factors, while nasogastric tube usage and higher intraoperative fluid volume were significantly associated with increased risk for complications and longer hospital stay.
Conclusion
High adherence to ERAS protocols in liver surgery is associated with fewer complications, reduced severe morbidity, and shorter hospital stay. These findings emphasize the importance of consistent protocol implementation to improve postoperative outcomes in hepatic surgery.
The resection of the caudate lobe for the treatment of hilar cholangiocarcinoma: our experience
Authors & Institutions
Teresa Perra & Alberto Porcu, Azienda Ospedaliero Universitaria di Sassari, Italy
Background
The routine resection of the caudate lobe for the treatment of hilar cholangiocarcinoma is still a debated procedure, despite the promising results in scientific literature. The aim of our study was to evaluate the safety, technical feasibility and main outcomes of the resection of the caudate lobe in the surgical treatment of patients affected by hilar cholangiocarcinoma at our institution.
Method
All patients who underwent surgical treatment for hilar cholangiocarcinoma between January 2008 and October 2023 at our institution were included in the study. Patients were divided into two groups based on whether or not they underwent caudate lobe resection (RLC and NRLC). The resection of the caudate lobe was an isolated procedure or combined with hepatectomy. We indicated the resection of the caudate lobe for all Bismuth-Corlette types II-IV hilar cholangiocarcinoma and when the distance of the tumor from the confluence of the hepatic ducts was lower than 2cm.
Results
44 patients were included in the study (23 RLC and 21 NRLC). Our results show an increase in overall survival in the RLC group, although it was not statistically significant when comparing the Kaplan-Meier curves. However, the trend of deaths in the study population should be noted. There was no significant difference between the two groups regarding deaths at 30 days and 12 months (when mortality is most influenced by possible postoperative complications). There was instead a significant difference in deaths at 24 months (when mortality could be most influenced by oncological radicality).
Conclusion
The resection of the caudate lobe is emerging as a fundamental part of the surgical treatment of hilar cholangiocarcinoma. Our results seem to confirm the positive results of some recent systematic reviews and meta-analyses, although further research is still needed.
Management and outcome of late post-pancreatectomy haemorrhage after pancreatoduodenectomy: experience from a high-volume UK tertiary centre
Authors & Institutions
Dobrzycka M, Chatzizacharias N, Bisht H, Raza SS, Dasari BV, Bartlett DC, Marudanayagam R, Roberts KJ, Sutcliffe RP, Papamichail M. Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham, Mindelsohn Way, Birmingham B15 2GW. United Kingdom
Background
Delayed bleeding after pancreaticoduodenectomy (PD) is a serious complication with significant morbidity and mortality. The aims of the study were to evaluate the incidence, management and outcomes of late (>24 hours) post-pancreaticoduodenectomy haemorrhage (PPH) after PD in a high-volume tertiary referral centre.
Method
A retrospective analysis of a prospectively maintained database of 1184 patients who underwent PD between 2011 and 2023 was performed. Patients who developed late PPH were identified. Diagnostic investigations included CT angiography, invasive angiography and endoscopy. Interventions included endovascular treatment (embolisation and/or stent graft placement) and laparotomy.
Results
Twenty-three patients (1.94%) developed late PPH, at a median onset of 15.6 days after surgery. 62.5% of late PPH cases were associated with pancreatic fistula. Eighteen patients (78.3%) underwent endovascular therapy, whilst five patients (21.7 %) required surgery. The gastroduodenal artery (GDA) was the most common source of bleeding (43.5%). In-hospital mortality was 17.4%.
Conclusion
Late PPH after PD is a rare but serious complication with a high mortality rate. Early detection with CT angiography and endovascular treatment is effective in managing most cases, reducing morbidity and mortality. Surgery remains a secondary option for refractory bleeding.
Immediate results of laparoscopic spleen-preserving distal pancreatectomy: Kimura vs Warshaw operation.
Authors & Institutions
Vervekin I., Trushin A., Kursenko R., Zacharenko A.
Pavlov First Saint Petersburg State Medical University. L’va Tolstogo str. 6-8, Saint Petersburg, Russia, 197022
Background
Laparoscopic distal spleen-preserving pancreatectomy is the standard of care for benign tumors of the body and tail of the pancreas. There are currently two methods: the Kimura-type, when the splenic vessels are preserved, and the Warshaw-type, when the splenic artery and veins are resected with preservation of short gastric vessels.
Method
The retrospective analysis included 60 patients who underwent distal pancreatectomy from February 2020 to February 2024. All patients were divided into 2 groups: 1 – Kimura-type (n = 34); 2 – Warshaw-type (n = 26).
There were no statistically significant differences in the baseline clinical characteristics of patients between the groups. A statistically significant difference in tumor size was found: larger tumors were more common in the WT group than in the KT group (2.85 cm vs. 4.7 cm, p = 0.026).
Results
The average duration of surgery in the WT group was 197.27 ± 42.09 min (95% CI 184.36 – 240.64) compared to the KT group (269.06 ± 70.95 (95% CI 227.74 – 319.95)), p = 0.006. No statistically significant differences were found between the groups in the analysis of blood loss, length of hospital stay, frequency of laparotomy, splenectomy, and reoperation. When assessing the incidence of POPF depending on the type of surgery, it was not possible to establish statistically significant differences (p = 0.474).
Conclusion
Both the Warshaw and Kimura techniques are safe and effective surgical approaches that provide similar results. The Warshaw method may be more advantageous in terms of the use of limited surgical resources without compromising the immediate surgical results of treatment.
The role of neoadjuvant chemotherapy (nCT) in the treatment of patients with resectable pancreatic cancer.
Authors & Institutions
Vervekin I., Trushin A., Kursenko R., Zacharenko A.
Affiliation. Pavlov First Saint Petersburg State Medical University. L’va Tolstogo str. 6-8, Saint Petersburg, Russia, 197022.
Background
The aim of the study was to evaluate of the efficacy and safety of neoadjuvant chemotherapy (nCT) using the mFOLFIRINOX regimen in the treatment of patients with resectable pancreatic cancer.
Method
The presented study is a single-center, prospective clinical trial. The primary endpoint is desease-free survival (DFS). Secondary endpoints: overall survival (OS), complication rate (Clavien-Dinо), histological tumor stage ypTN, tumor response to treatment (CAP grading system), R0 resection rate, resectability. The study includes patients with pancreatic adenocarcinoma that meets the resectability criteria (according to NCCN 2025). Patients (n=64) are randomized in a 1:1 ratio either to the control group (radical surgery + aCT) or to the experimental group (nCT mFOLFIRINOX + radical surgery).
Results
The median DFS was 10.7 months (95% CI 6.9–13.7) in the control group and 14.9 months (95% CI 6.4–19.4) in the NAC group (p=0.035). The median OS was 16.9 months (95% CI 7.9–20.4) in the control group and 21.7 months (95% CI 12.4–24.4) in the nCT group (p=0.031). The surgical resection rate was 71.8% in the control group and 84.6% in the nCT group (p=0.017). The R0 resection rate was 57% in the control group and 81.2% in the nCT group (p=0.037). The frequency of vascular resection (portal vein) was 17.5% in the control group and 9% in the nCT group (p=0.04).
Conclusion
The study demonstrated statistically significant superiority in the nCT group in terms of survival, resectability and the rate of R0 resections. The rate of postoperative complications did not differ statistically between the groups. Thus, nCT for resectable pancreatic cancer is a promising method.
Machine Learning for Individualized Survival Prediction in Colorectal Liver Metastases
Authors & Institutions
Ottavia Cicerone(1), Simone Famularo(2), Federica Lucev(3), Alessandro Vanoli(4), Anna Pagani(5), Marcello Maestri(6)
1. University of Pavia, Fondazione IRCCS Policlinico San Matteo, Chirurgia Generale I
2. Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University of the Sacred Heart, Rome, Italy; IRCAD, Research Institute Against Cancer of the Digestive System, 1 Place de l’Hôpital, Strasbourg, 67091, France
3. Fondazione IRCCS Policlinico San Matteo, Radiologia, Pavia, Italy
4. Fondazione IRCCS Policlinico San Matteo, Anatomia Patologica, Pavia, Italy
5. Fondazione IRCCS Policlinico San Matteo, Oncologia, Pavia, Italy
6. Fondazione IRCCS Policlinico San Matteo, Chirurgia Generale I
Background
The aim of this study is to develop and validate “LiverMetsApp”, a machine learning-based interactive platform for predicting survival in patients undergoing liver resection for colorectal liver metastases (CRLM). By integrating key prognostic variables into a Cox proportional hazards model, the tool provides individualized, patient-specific survival estimates to support clinical decision-making.
Method
Data from 264 CRLM patients were analyzed. Categorical variables were transformed via one-hot encoding, and missing data were handled using an iterative imputation algorithm in Python. Feature selection was performed using LASSO regression with 5-fold cross-validation, and selected variables were entered into a Cox proportional hazards model. Model performance was assessed by concordance index, log-likelihood ratio test, and ROC analysis. The final model was implemented in “LiverMetsApp” for interactive survival curve generation.
Results
Significant predictors in the multivariate analysis included pre-colectomy chemotherapy (HR=0.60, p=0.04), synchronous metastases (HR=1.75, p<0.005), number (HR=1.78, p=0.01) and size (HR=1.53, p=0.02) of metastases, and post-metastasectomy chemotherapy (HR=0.68, p=0.02). The model demonstrated good performance (C-index = 0.68, log-likelihood ratio = 54.01, p < 0.005) and a ROC AUC of 0.73, confirming its discriminative ability. The web application was developed and is freely accessible(1).
1. Cicerone O. LiverMetsApp 2025 [ https://livermetsapp-semqscsfsf7yq94c6f3jpu.streamlit.app.]
Conclusion
“LiverMetsApp” integrates machine learning and Cox regression to deliver personalized survival predictions for CRLM patients. By enabling individualized prognostic simulations, it may enhance treatment planning, facilitate multidisciplinary discussion, and serve as a valuable educational resource.
Distal Splenopancreatectomy After Percutaneous Portal Recanalization in the setting of BD-IPMN and Pancreatic Adenocarcinoma Complicated by Portal Cavernoma: A Case Report
Authors & Institutions
Marin Federico Alberto Niccolo‘ (1,2), Guizzetti Michela (1), Bonaffini Pietro Andrea (1), Salvatore Greco (1), Costantino Daniela (1), Carbone Francesco Saverio (1), Pinelli Domenico (1,2)
(1) Ospedale Papa Giovanni XXIII (2) Università degli studi di Milano UNIMI
Background
The coexistence of a pancreatic branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) and ductal adenocarcinoma of the pancreatic body-tail, complicated by portal cavernoma, requires complex management. Abdominal surgery in portal hypertension patients carries a risk of bleeding and liver failure. Splenectomy reduces hepatic venous return and raises the risk of mesenteric vein thrombosis.
Method
A 70 y.o. woman with hypertension and dyslipidemia, previously undergoing laparoscopic cholecystectomy converted to open surgery for bleeding, showed intraoperative vascular anomalies. CT revealed portal vein thrombosis, periportal varices, and main pancreatic duct dilation (39 mm) with a cystic mass and enhancing nodules near the splenic vein. EUS-FNA confirmed ductal adenocarcinoma. Platelets were 111,000/mm³, aPTTr 1.77; liver function and tumor markers were normal. Anticoagulation was initiated. MRI, EGD and CT showed chronic portal cavernoma and F1 esophageal varices, without metastases.
Results
To decompress portal circulation, a TIPS via transplenic/transjugular access was attempted but failed for early thrombosis. Angioplasty with stenting of the portal trunk–spleno-mesenteric confluence succeeded. One week later, distal splenopancreatectomy was performed. Postoperative course included grade A pancreatic fistula, bowel obstruction requiring relaparotomy, anemia with spontaneous hemoperitoneum and bacteremia. She was discharged on POD 51. Histology: intraductal tubulopapillary neoplasm with invasive carcinoma (pT1cN0). Follow-up imaging showed no recurrence, TIPS and stent patent.
Conclusion
In selected cases, portal cavernoma does not exclude the feasibility of curative distal splenopancreatectomy preceded by percutaneous portal recanalization. This strategy demands careful multidisciplinary management.
Transition from open to full robotic living donor left liver graft procurement for pediatric recipients-Experience from a western center
Authors & Institutions
Lucas Pflieger MD 1, Xavier Muller PhD 12, Guillaume Rossignol PhD123, , Mathias Ruiz MD4 , Remi Dubois MD3, Teresa Antonini, MD 25 , Kayvan Mohkam, PhD 123, Jean-Yves Mabrut, PhD12.
1 Department of General Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, France
2 Hepatology Institute of Lyon, UMR 1350 PaThLiv, IHU EVEREST
3 Department of Pediatric Surgery and Liver Transplantation, Femme Mere Enfant University Hospital, Lyon, France.
4 Department of Pediatric Hepatology, Gastroenterology and Nutrition, Femme Mere Enfant University Hospital, Lyon, France
5 Department of Hepatology Croix-Rousse University Hospital, Hospices Civils de Lyon, France.
Background
Today, the majority of minimally invasive living donor hepatectomies (LDH) are performed with a robotic approach and 41% of the centers performing R-LDH transitioned directly from open to the robotic approach. In this context, there is an urgent need to assess the safety of the transition from open to R-LDH.
Method
In this retrospective single-center study in a high volume tertiary hepatobiliary and liver transplant center from France, we report all consecutive LDH performed from September 2019 to March 2025 for pediatric recipients. This IDEAL Stage 2a study assesses the donor safety of R-LDH in comparison to open-LDH. The primary safety endpoint is the absence of major donor morbidity (Clavien-Dindo Grade>II) after 90 postoperative days.
Results
During the study period, 23 LDHs were performed, with 16 (70 %) open LDHs and 7 (30%) robotic LDHs. The majority of LDHs were G23 (n=21, 91%).
At 90 days, there were no CD>II complications in the R-LDH and open group.
The operative duration of robotic-LDH was significantly longer (356 min vs 243 min, p=0.026) but intraoperative blood loss was further reduced (50 ml vs 125 ml p<0.001) and no conversion was required.
After a median overall follow-up of 25 months, graft and recipient survival was 100% in both groups.
Conclusion
In conclusion, the transition from open to R-LDH in the setting of a low-volume LDH center can be achieved without compromising donor safety. An extensive experience in minimal-invasive HPB surgery contributes to a safe transition from open to R-LDH.
Laparoscopic versus open liver resection for huge hepatocellular carcinoma (≥ than 10 cm): a multicenter propensity score - matched analysis from Eastern and Western referral centers
Authors & Institutions
Gianluca CASSESE, Fabio GIANNONE, Federica CIPRIANI, Antonio CUBISINO, Bruno BRANCIFORTE, Alessandro TROPEA, Fabio BENEDETTI, Fabrizio ROMANO, Salvatore GRUTTADAURIA, Guido TORZILLI, Mickael LESURTEL, Patrick PESSAUX, Francesca RATTI, Ho-Seong HAN, Fabrizio PANARO.
Background
There is still poor evidence about the safety and feasibility of minimally invasive liver surgery (MILS) for huge (> 10 cm) hepatocellular carcinomas (HCC). The aim of this study was to assess the short- and long- term outcomes of MILS versus open liver resection (OLR) for patients with huge HCC.
Method
Data regarding all consecutive patients undergoing liver resection for huge HCC were retrospectively collected from Asian (South Korean) and European (Italian and French) referral HPB centers. The cases were propensity-score matched for age, center, extent of the resection, tumor size, tumor number.
Results
A total of 198 patients were included in the study. Before matching there were statistically significant differences in tumor size (p<0.01) and rates of major hepatectomies performed (p=0.03). After PSM two cohorts of 39 patients were obtained, with no statistically significant differences in all the compared preoperative characteristics. No significant differences were found in terms of major complications, in-hospital mortality and operative time, between the matched cohorts. The length of hospital stay was significantly lower after LLR (median 7 vs. 10 days, p < .01), as well as the intraoperative estimated blood loss (median 500ml vs 80 ml, respectively; p=0.02) and the rates of intraoperative transfusions (25.6% vs 48.7%, respectively; p= 0.03). After a median follow-up of 61 (±7) months, there were no significant differences between OLR and LLR in both median OS (69 vs. 59 months, p = .74, respectively) and median DFS (12 vs. 10 months, p = .48, respectively).
Conclusion
MILS for huge HCC can be safe and effective in selected cases in referral centers, being able to reduce intraoperative blood loss, and to shorten median hospital stay.
Efficacy and Safety of Low-Dose Tacrolimus Monotherapy in Liver Transplantation: Experience from a Level-IV Hospital in Latin America (Cali, Colombia)
Authors & Institutions
Juan Manuel Rico Juri¹†, Anabel Vanin Aguas¹, Felipe Castro Villegas¹, Michael Zapata Palomino¹, Ilich Andrei Zúñiga Gaitán², Jesús David Charfuelan Caicedo³, Carolina Téllez Fina³
¹Liver Transplant Unit, Clínica Imbanaco, Cali, Colombia – transplant surgeons, general surgeon.
²Universidad del Valle, Cali, Colombia – general surgery resident.
³Pontificia Universidad Javeriana Cali, Colombia – general practitioners.
†Dr. Juan Manuel Rico Juri is also a member of the Compagnons Hépato-Biliaires.
Background
The present study aims to address this knowledge gap by describing the experience of a level-IV hospital in Cali, Colombia, with the use of tacrolimus monotherapy at different plasma levels. The primary objective is to evaluate immunological efficacy, metabolic safety, and one-year patient and graft survival, comparing outcomes among patients with tacrolimus levels <5 ng/ml, 5–10 ng/ml, and >15 ng
Method
This was a retrospective observational study conducted at Clínica Imbanaco, a level IV hospital in Cali, Colombia (Latin America), between April 2018 and May 2024. A total of 119 liver transplant recipients were included and classified according to their immunosuppressive regimen: low-level tacrolimus monotherapy (<10 ng/ml) or dual therapy with mycophenolate. Clinical, surgical, and immunological variables were evaluated, including metabolic complications, acute rejection, liver function, infections, and one-year survival.
Results
Tacrolimus monotherapy was used in 86.6% of patients. Levels between 5 and 10 ng/ml were associated with lower rejection rates (8.7%), preserved liver function, and a low infection rate. Levels <5 ng/ml were linked to increased rejection (21.1%) and infections (13.5%), while levels >15 ng/ml were associated with liver dysfunction. Compared to dual therapy, monotherapy was associated with lower rates of renal insufficiency, hypertension, and de novo diabetes, without differences in patient or graft survival.
Conclusion
Tacrolimus monotherapy at 5–10 ng/ml is safe and effective in selected patients, reducing toxicity without affecting liver function, immunity, or survival. This large Latin American single-center experience shows its feasibility and value in resource-limited settings.
Robotic Deceased Donor Liver Transplantation: A Video of Technical Aspects
Authors & Institutions
Mariya Ekimova
Dieter Broreing Organ transplant Center of Excellence, King Faisal Specialist Hospital and Research centre.
Background
To demonstrate the feasibility and potential advantages of a fully robotic deceased donor liver transplantation (DDLT) performed at our institution.
Method
A fully robotic DDLT was performed using the Da Vinci Xi system in a patient with end-stage liver disease due to NASH cirrhosis and hepatocellular carcinoma (SEG 7, 3 cm) with a MELD score of 30. Total native liver hepatectomy and graft implantation were conducted through a Pfannenstiel incision.
Results
The operation lasted 6 hours with a warm ischemia time of 30 minutes. No intraoperative or postoperative complications occurred. Blood loss was minimal (300 mL). The patient was discharged on postoperative day 7.
Conclusion
Robotic DDLT allows precise dissection around the portal triad and retrohepatic inferior vena cava, minimizing blood loss and enhancing surgical accuracy. Preliminary data suggest benefits for both patient and surgeon. Further studies are needed to assess long-term outcomes and compare this approach.
Tumor response scoring systems for pancreatic ductal adenocarcinoma: A Systematic Review
Authors & Institutions
Roberta Vella, Elvira Adinolfi, Beatrice Belmonte, Gabriella Pittau, Alessandro Anastasi, Guido Martignoni, Stefano Crippa, Giovanni Butturini, Isabella Frigerio.
Background
This review aims to provide a comprehensive review of existing literature on Tumor response scoring (TRS) systems for Pancreatic ductal adenocarcinoma (PDAC), highlighting current limits of existing systems and shedding light into novel ancillary techniques that might guide patient stratification following induction therapies.
Method
We searched PubMed, Scopus and the Cochrane database for English-language studies evaluating the prognostic role of TRS systems and novel regression scoring systems for PDAC. Literature search was conducted and reported according to PRISMA 2020 guidelines, and risk of bias was assessed through the QUIPS Cochrane tool.
Results
Several TRS systems were identified, varying in grading criteria and complexity. Despite their widespread use, these systems lack reproducibility and prognostic accuracy, particularly in distinguishing true tumor regression from pre-existing stromal characteristics. Recent evidence supports combining histopathological evaluation with radiological, serological, and molecular biomarkers—such as CA 19.9, circulating tumor DNA (ctDNA), KRAS mutation profiles, transcriptomic subtypes, and perineural invasion scoring—to accurately predict pathological complete response and optimize patient therapy.
Conclusion
Current TRS provide useful prognostic information, their limitations underscore the need for integrated histopathological, molecular, and imaging-based criteria. A multiparametric TRS system will be essential for guiding personalized therapeutic decision-making in the era of precision oncology.
The Role of “Conservative” Resection Strategy after neoadjuvant treatment for borderline/locally advanced PDAC with arterial involvement: a single-centre retrospective observational study
Authors & Institutions
Roberta Vella, Elisa Bannone , Alessandro Giardino, Isabella Frigerio, Martina Guerra, Erica Pizzocaro, Laura Bignotto, Filippo Scopelliti, Paolo Regi, Camillo Aliberti, Guido Martignoni, Roberto Girelli, Marcello Lino, Paolo Pederzoli, Giovanni Butturini.
Background
Recent advances in multimodal therapies have increased the potential for resectability of borderline
resectable and locally advanced Pancreatic ductal adenocarcinoma (PDAC). We herein describe the
conservative resection strategy adopted at our Institution and the oncological outcomes of patients with
PDAC and arterial involvement.
Method
This retrospective single-centre study included patients diagnosed with PDAC and radiologic evidence of
arterial involvement who underwent surgical exploration between January 2014 and June 2024. All patients received induction chemotherapy (± radiotherapy). Survival outcomes were analysed using the Kaplan–Meier and Cox proportional hazards models. Logistic regression analyses were used to identify predictors of resectability and recurrence.
Results
76 patients were included; 59 underwent pancreatic resection with arterial divestment (AD) and 17 were deemed unresectable at laparotomy. Neoadjuvant FOLFIRINOX was significantly associated with increased odds of resection (HR = 3.23, 95% CI: 1.59–9.90, p = 0.040). Median OS from diagnosis was 33 months (29–39) in resected patients and 26 months (16–29) in non-resected patients (p = 0.0176). Surgical resection and Ca 19,9 normalization after induction therapy were associated with reduced mortality risk (HR = 0.38, 95% CI: 0.19–0.75, p = 0.005 and HR=0.56, 95% CI: 0.35-0.88, p=0.014).
Conclusion
These findings highlight the value of multimodal strategies in managing PDAC with arterial involvement. AD represents a valuable technique associated with acceptable outcomes in selected patients. Future interventional prospective studies are needed to optimize patient selection.
Early Laparoscopic Cholecystectomy Post Endoscopic Retrograde cholangiopancreatography in Patients of Cholelithiasis with Choledocholithiasis: An Observational Study
Authors & Institutions
Sajad Ahmad Khoja, Ankit Uppal, Sheikh Bisma Ramzan, Showkat Ahmad Kadla, Haris Bashir.
institution: GOVT. MEDICAL COLLEGE , SRINAGAR, kashmir India
Background
to study the safety and efficacy of early LC post-ERCP in terms of intraoperative parameters like, operative time, adhesions (NASSAR grading), calots triangle anatomy, conversion to open, and complications.
Method
A total of 50 patients of CL with choledocholithiasis (CDL), aged more than 18 years, were enrolled for the study,which took place over a period of 18 months. The said patients were subjected to pre-operative ERCP for biliary clearance and were taken upfor laparoscopic surgery within 72 hours of ERCP, wherein the difficulty of operation/operative time/conversion to open was decided accordingto NASSAR grade scale.
Results
Themajority of the enrolled patients were classified as NASSAR grade II(n = 24) with a mean operative time of 43.4 minutes, followed bygrade IV (n = 14), grade II (n = 10) and grade I (n = 2) with a meanoperative time of 91.3 minutes, 55.2 minutes, and 36 minutesrespectively (Table 2). One of the patients (2%) was converted toopen following dense adhesions and frozen anatomy. About 40patients (80%) underwent LC within 48–72 hours of ERCP while 10
patients (20%) before 48 hours only.
Conclusion
Our study shows that LC within 3 days of ERCP is safe, and cost-effective.
Critical View of Safety in Laparoscopic Cholecystectomy: A Prospective, Observational Study
Authors & Institutions
Sajad Nazir Malla, Waseem Ul Rahman Dar, Haris Bashir, Imtiyaz Ahmad Malik, Bilal Ahmad Lone.
institution: GOVT. MEDICAL COLLEGE , SRINAGAR, kashmir India
Background
To observe the percentage of patients in whom CVS was attained during laparoscopic cholecystectomy, percentage of patients where bailout procedures were needed and the type of bail out procedure adopted.
Method
conducted in the Department of Minimal Access and General Surgery, Govt. Medical College Srinagar at Kashmir, over a period of 6 months. A total of 55 patients of symptomatic cholelithiasis, aged >20 years were enrolled. Sample selection was done using a purposive sampling technique. Information regarding age, gender, clinical presentation, and etiological factors was collected through an interview-based questionnaire from the patients or their attendants.collected data as i) operative time;ii) GB wallthickness, 3, BDI, 4 complications, 5. LOS. F/U for 6wks post op.
Results
(52.73%) of thepatients were in the age group of 40-59 years, followed by (29.09%) in 20-39 years age group. male-female ratio was 1:5. Critical view of safety (CVS)was attained in 50 patients (90.9%), while 5 patients had difficulties: difficulty in dissection ofcalot’s triangle in 5 cases, dense adhesions were found in 3 cases and 1 had perforated llbladder.Significant differences were observed between two groups (CVS attained and not attained) interms of operative time, gallbladder wall thickness and total hospital stay p<0.001). Bail out proceduresopted-conversion to open, lap fundus first.
Conclusion
Attainment of CVS makesthe procedure easy and convenient. Variouspredictive factors that lead to difficult gall bladderincluded difficult Calot’s triangle dissection,dense adhesion and thickened gall bladder wall.All these factors play predictive role for variousbail-out procedures or conversion .
Lapro-cystoscopic clearance in OCH & Roux-en Y hepaticojejunostomy.
Authors & Institutions
Prof Iqbal Saleem, Dr Haris Bashir, Dr Mudasir, Dr Anyees
institution: GOVT. MEDICAL COLLEGE , SRINAGAR, kashmir India
Background
Achieving clearance of sectoral ducts in patients of OrientalCholangioHepatitis using laparoscopy and help of cystoscopy.
Method
Laparoscopy and cystoscopy in absence of choledocoscopy, for confirmation and clearance of sectoral ducts.
Results
cystoscopic guidance stands a good alternative for good visualization, guided removal of calculi, even in the higher up ducts of Right or left hemiliver.
Conclusion
in absence of choledochoscope, cystoscope whether rigid/flexible can be used effectively to treat sectoral/ tertiary duct calculi in OCH.
Impact of laparoscopic resection for access to the waiting list of a single regional transplant center in southern Italy: entry and dropout flows’ analysis
Authors & Institutions
Duilio Pagano, Roberta Vella, Fabrizio di Francesco, Sergio Li Petri, Pasquale Bonsignore, Sergio Calamia, Alessandro Tropea, Caterina Accardo, Ivan Vella, Noemi Di Lorenzo, Salvatore Gruttadauria
Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT-UPMC.
Background
The aim of this study was to analyse the impact of laparoscopic liver resection for access to the waiting list of a single regional center for liver transplantation in a region with a donor shortage in southern Italy.
Method
We retrospectively analyzed patients with early/intermediate HCC treated from 2016–2023. Patients were grouped as surgically treatable or resectable/transplantable based on age, liver function, and comorbidities. MWTA-treated patients were included as surgically treatable. Linear correlation assessed LLR vs. transplant list metrics. Cox regression analyzed recurrence risk post-resection. Competing risk analysis evaluated 1-year probabilities of dropout, death, and transplant for listed patients.
Results
From 2016–2023, 887 patients with HCC or ESLD were included; 563 had early/intermediate HCC, and 320 underwent resection or thermoablation. Of 243 listed for transplant, 91 potentially transplantable patients were resected. Hepatic and laparoscopic resections increased over time. An inverse correlation (ρ=-0.82, p=0.023) was found between LLRs and ITT dropout/enrollments. Tumor size and multifocality predicted recurrence. HCC patients had lower dropout and higher transplant rates than non-HCC patients at 3, 6, and 12 months.
Conclusion
Minimally invasive surgical therapies for HCC have a specific impact on the drop-out rate of the overall ITT population and the waiting time for transplantation for transplanted HCC patients.
Early Biliary Complications After Pancreaticoduodenectomy: A Ten-Year Single-Center Experience
Authors & Institutions
O.Usenko, O. Lytvyn, S.O. Motelchuk
State institution “National Scientific Center of surgery and transplantation named after O.O. Shalimov to National Academy of medical sciences of Ukraine”, 30, Akademika Shalimova str., Kyiv, Ukraine, 03126
Background
Method
Patients were divided into groups: without postoperative fistula, with pancreatic fistula, with biliary fistula, and with combined pancreatico-biliary fistula. Pancreatic fistula was defined according to international criteria as the presence of fluid with amylase activity exceeding three times the upper normal serum limit within the first three postoperative days. Biliary fistula was diagnosed by bile in the drainage fluid with bilirubin concentration more than three times the upper normal serum level after the third postoperative day, or based on imaging (percutaneous transhepatic cholangiography, drainage cholangiography, or intratubular cholangiography) confirming communication between the extrahepatic bile ducts and the peritoneal cavity. Patients with amylase-rich fluid but without signs of biliary leakage were excluded. Combined pancreatico-biliary fistulas were defined according to the same criteria as isolated biliary fistulas, with additional presence of amylase-rich fluid.
Results
We retrospectively analyzed data from 421 patients who underwent pancreaticoduodenectomy between November 2014 and December 2024 for malignant and benign periampullary tumors, as well as complicated chronic pancreatitis.
Indications:
– Adenocarcinoma — 45% (n=189)
– Intraductal papillary mucinous neoplasm (IPMN) — 21% (n=88)
– Neuroendocrine tumors — 10% (n=42)
– Ampullary carcinoma — 8% (n=34)
– Cholangiocarcinoma — 6% (n=25)
– Chronic pancreatitis — 4% (n=17)
– Duodenal carcinoma — 2% (n=8)
– Others — 4% (n=18)
Preoperative biliary drainage was performed in 31% (n=130), and positive bile cultures were found in 35% (n=147). At the time of surgery, jaundice was present in 49% (n=206). A common bile duct diameter ≤5 mm was observed in 24% (n=101).
Hepaticojejunostomy technique:
– Interrupted sutures — 41% (n=173)
– Continuous sutures — 11% (n=46)
– Combined technique — 48% (n=202)
Postoperative complications:
– Biliary fistula — 3% (n=10)
– Pancreatic fistula — 22% (n=92)
– Delayed gastric emptying (DGE) — 25% (n=105)
– Combined hepaticojejunostomy and pancreaticojejunostomy leakage — 0.5% (n=2)
– No anastomotic failure — 72% (n=303)
The mean age was 61±9.3 years; 52% male (n=219) and 48% female (n=202). Postoperative mortality was 4% (n=17): surgical complications 62% (n=11; ischemic 2, pancreatic fistula 4, hemorrhage 5), cardiopulmonary 23% (n=4), and other causes 15% (n=2).
Risk factors for early biliary complications: sex, tumor nature (benign/malignant), pylorus-preserving technique, bile duct diameter <5 mm, presence of pancreatic fistula, and the use of 6/0 suture material for biliary anastomosis. All hepaticojejunostomy strictures occurred in patients with a duct diameter <5 mm. Transient jaundice was significantly more frequent in patients with bile duct diameter <5 mm. Cholangitis was more common in tumors of the biliary and periampullary region.
Conclusion
Early biliary fistulas are relatively rare but their combination with pancreatic fistula significantly increases the risk of severe complications and mortality. The most important independent risk factor is a narrow bile duct diameter, highlighting the critical role of surgical technique. The use of 6/0 suture material may contribute to ischemic injury and stricture formation. Approximately 50% of biliary fistulas close spontaneously if intra-abdominal drainage is maintained, with zero mortality from isolated biliary fistulas. Minimally invasive management strategies are effective and help avoid reoperation.
Preoperative Endoscopic Biliary Drainage as a Risk Factor for Increased Postoperative Complications After Pancreaticoduodenectomy
Authors & Institutions
O.I. Lytvyn, S.O. Motelchuk
State institution “National Scientific Center of surgery and transplantation named after O.O. Shalimov to National Academy of medical sciences of Ukraine”, 30, Akademika Shalimova str., Kyiv, Ukraine, 03126
Background
Preoperative endoscopic biliary drainage (EBD) before pancreaticoduodenectomy (PD) is performed to improve liver function and correct coagulation abnormalities, which may affect postoperative recovery in patients with obstructive jaundice. The rationale behind EBD is to stabilize the patient’s condition and improve surgical outcomes. However, the increasing incidence of postoperative and infectious complications highlights the need to clearly define the indications for preoperative biliary decompression and to avoid its routine use.
Method
A retrospective analysis was conducted at the Shalimov National Scientific Center of Surgery and Transplantology (Kyiv, Ukraine). Between April and December 2024, PD was performed in 91 patients, of whom 49 underwent preoperative EBD. All patients were divided into two groups: with EBD and without EBD. Clinical characteristics and the incidence of postoperative complications were compared between the groups.
Results
The overall incidence of postoperative complications was significantly lower in the non-EBD group compared to the EBD group (23.8% vs. 53%, p < 0.05). The incidence of clinically significant postoperative pancreatic fistula was also lower in the non-EBD group (12.2% vs. 28.2%, p = 0.003). The rate of infectious complications was 9.5% in the non-EBD group compared to 20.4% in the EBD group (p < 0.05).
Conclusion
Preoperative EBD significantly increases the risk of postoperative and infectious complications in patients undergoing PD. The findings confirm that patients who undergo endoscopic retrograde biliary decompression before PD are at higher risk of developing external pancreatic fistulas and infectious complications.
HBPSurG 2026
Clinical Audit: CEA Follow-Up After Liver Resection for Colorectal Liver Metastases
Authors & Institutions
Esther Sleigh, University Hospitals Southampton
Declan McDonnell, University Hospitals Southampton
Lulu Tanno, University Hospitals Southampton
Background
Carcino-embryonic antigen (CEA) surveillance in patients with colorectal liver metastases (CRLM) remains poorly defined. CEA demonstrates good specificity, with highest sensitivity for hepatic metastases, yet despite this, no consensus exists. Current literature recommends CEA monitoring every 3-6 months for 2-5 years.
Method
This audit evaluated standard of care for peri-operative CEA surveillance in patients undergoing liver resections for CRLM at a tertiary HPB centre. Patients undergoing surgical resection for CRLM in 2024 who received at least 18 months of biochemical and radiological follow-up were retrospectively identified. The audit standard was defined by the colorectal team’s current practice: CEA testing every 3-4 months for the first 3 years, followed by 6-monthly testing thereafter, consistent with current literature.
Results
Forty-eight patients (mean age 62; 60% male) underwent CRLM resections. Only 25% received adequate CEA monitoring in line with the audit standard, while 27% had no CEA measurements recorded. 96% of patients had surveillance imaging identifying a 54.2% rate of recurrence. This discrepancy between good imaging surveillance and poor CEA monitoring perhaps suggests systemic limitations rather than patient-driven factors. Pre-operative and early post-operative CEA monitoring was comparable, with higher proportion of testing performed 6-months post-operatively.
Conclusion
CEA surveillance following CRLM resection is inconsistently performed. Standardisation of CEA monitoring is required across the region to ensure consistent follow-up, with cost-analysis needed to support sustainable follow-up protocols. The small cohort and absence of protocol limits interpretation.
Expression of EGFR and Ki-67 in Gall bladder Carcinoma
Authors & Institutions
Dr Mukund Mangarai
Dept of Surgical gastroenterology
Bangalore medical college and research institute, Bengaluru. India.
Dr. Prof. Poras Chaudhary
Department of General Surgery
Dr. RML HOSPITAL, New delhi. India.
Background
Gall bladder carcinoma (GBC) is a multifactorial disease process with several factors influencing prognosis. GBC is associated with the expression of multiple cell proliferating markers such as Ki-67/EGFR. This study demonstrates the expression of EGFR and Ki-67 in GBC and their co-relation with the stage of disease.
Method
This was a single centre prospective study including 60patients of GBC. Expression of EGFR and Ki-67 was assessed by immunohistochemistry on formalin-fixed paraffin-embedded tumor tissue blocks. Group comparisons for continuously distributed data were made using independent sample t test. Chi square test was used for group comparison for categorical data. The level of significance α=0.05 and p-value <0.05 was considered statistically significant.
Results
There was a positive correlation between EGFR and presence of gall stones, gall bladder polyp, T stage, lymph node involvement, presence of metastasis and tumor differentiation. However, the association of these variables with Ki-67 was statistically insignificant.
Conclusion
EGFR and Ki-67 were observed in > 70% of GBC cases and targeted therapy for EGFR can give a ray of hope for gall bladder cancer patients as a curative intent and as palliative therapy in advanced stage of disease.
Single-cell Transcriptomics Identifies F11R as a Stromal Mediator Linking Non-alcoholic Fatty Liver Disease and Intrahepatic Cholangiocarcinoma, with Icaritin as a Potential Intervention
Authors & Institutions
1.Zhejiang Key Laboratory of Multi-omics Precision Diagnosis and Treatment of Liver Diseases, Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, 310016, Hangzhou, China
2.Zhejiang Minimal Invasive Diagnosis and Treatment Technology Research Center of Severe Hepatobiliary Disease, Zhejiang Research and Development Engineering Laboratory of Minimally Invasive Technology and Equipment 310016, Hangzhou, China
3.Zhejiang University Cancer Center, 310058, Hangzhou, China
4.Liangzhu Laboratory, Zhejiang University Medical Center, 311121, Hangzhou,China
5.School of medicine, Shaoxing University, Shaoxing, Zhejiang, 312000, China
6.School of Basic Medical Sciences and Forensic Medicine, Hangzhou Medical
Background
To identify stromal regulators linking non-alcoholic fatty liver disease (NAFLD) and intrahepatic cholangiocarcinoma (ICC), with a focus on fibroblast-associated mechanisms, and to evaluate whether F11R represents a druggable microenvironmental target and whether icaritin may act as a potential intervention.
Method
We integrated single-cell RNA-seq from ICC (GSE138709) and NAFLD (GSE202379) with spatial transcriptomics, fibroblast-specific differential expression, enrichment analysis, pseudotime analysis, in silico F11R knockout/overexpression, drug-gene association analysis, and molecular docking. Functional validation was performed in ICC-associated fibroblasts, cholangiocarcinoma cells, and ICC organoids using proliferation, invasion, autophagy, conditioned-medium, and direct co-culture assays.
Results
Fibroblast remodeling was evident in both NAFLD and ICC. Fibroblast gene signatures were enriched in extracellular matrix organization, adhesion signaling, and stromal pathways. F11R emerged as a key candidate, supported by pseudotime and spatial transcriptomic analyses. Icaritin suppressed ICC-CAF proliferation and invasion, reduced F11R expression, and induced autophagy-related changes. F11R knockdown produced similar effects and weakened CAF-mediated support of cholangiocarcinoma cells and ICC organoids, with reduced EPCAM expression in conditioned-medium and direct co-culture models.
Conclusion
NAFLD and ICC share a fibroblast-centered stromal program, with F11R acting as a context-dependent mediator. Targeting the F11R-associated stromal axis, potentially with icaritin, may represent a therapeutic strategy for ICC in the setting of NAFLD-related microenvironmental remodeling.
Bile leak after elective laparoscopic cholecystectomy: association with transcystic instrumentation and cystic duct closure method
Authors & Institutions
du Plessis, Maria C.; Petracchi, Enrique J.; Quesada, Bernabé M.; Varela, Jose R.; Comodo, Oriana B.; Baglietto, Nicolas F.; Canullan, Carlos M.; Zandalazini, Hugo I.
Division of General Surgery, Hospital General de Agudos Dr. Cosme Argerich, Pi y Margall 750, C1155AHD, Autonomous City of Buenos Aires, Buenos Aires, Argentina.
Background
The aim of this study was to evaluate the association between cystic duct (CD) closure method, transcystic instrumentation (TCI), and the occurrence of bile leak (BL) after elective laparoscopic cholecystectomy (LC).
Method
A retrospective analysis of all elective LC performed between May 2014 and May 2024 was conducted. Patients requiring procedures beyond TCI (including preoperative ERCP, choledochotomy, biliary-enteric anastomosis) were excluded. All procedures followed the principles of safe cholecystectomy. Data were obtained from a prospectively maintained database.
Results
2910 patients (95.5%) met inclusion criteria. CD closure methods were TC in 2,332 patients (80.1%), ET in 543 (18.7%), laparoscopic sutures in 26 (0.9%), and LPC in 9 (0.3%). Eight BL were identified (0.27%). TCI was required in 466 patients (16.0%). In the TCI subgroup, the most frequently used closure method was ET in 266 patients (57.1%). The incidence of BL was higher in patients who underwent TCI compared with those who did not (0.86 vs 0.16%; OR 5.28, 95% CI 1.32-21.19; Fisher’s exact test p = 0.018). No significant association was found between BL and the method of CD closure, either in the overall cohort or in the TCI subgroup.
Conclusion
TCI was associated with a higher incidence of BL, with no difference detected across CD closure methods, although analyses were underpowered. These findings do not argue against TCI itself, but rather underscore the importance of careful technique, minimization of ductal trauma and of appropriate selection of the CD closure method.
Heterogeneity in Tokyo Guidelines 2018 grade II acute cholecystitis: association of local complications with operative difficulty and postoperative morbidity
Authors & Institutions
du Plessis, Maria C.; Martínez Maldonado, Arturo J.; Varela, José R.; Quesada, Bernabé M.; Baglietto, Nicolas F.; Comodo Oriana B.; Canullan, Carlos M.; Zandalazini, Hugo I.; Petracchi, Enrique J.
Division of General Surgery, Hospital General de Agudos Dr. Cosme Argerich, Pi y Margall 750, C1155AHD, Autonomous City of Buenos Aires, Buenos Aires, Argentina.
Background
This study evaluated whether patients classified as Tokyo Guidelines 2018 (TG18) grade II due to local complications had greater operative difficulty and postoperative morbidity, and explored factors associated with this subgroup.
Method
A retrospective observational study including all TG18 grade II AC patients undergoing laparoscopic cholecystectomy was performed. Patients were stratified into a locally complicated group (LCG) and a non-locally complicated group (NLCG). Multivariable logistic regression identified factors associated with LCG.
Results
A total of 207 patients were analyzed; 70 (33.8%) were classified as LCG. Compared with NLCG, LCG patients had greater operative difficulty (92.9% vs 70.8%; OR 5.4, 95% CI 1.8–15.7), higher overall postoperative complications (12.9% vs 1.5%; OR 10.0, 95% CI 2.0–48.6), major complications (7.1% vs 0.7%; OR 10.5, 95% CI 1.1–97), and bile leak (7.1% vs 0.7%; OR 10.5, 95% CI 1.1–97). Age (OR 1.02, 95% CI 1.00–1.04), male sex (OR 2.39, 95% CI 1.27–4.50), and comorbidities (OR 4.28, 95% CI 1.77–10.33) were independently associated with LCG.
Conclusion
Among TG18 grade II AC patients, LCG represent a higher-risk subgroup with greater operative difficulty and worse postoperative outcomes.
Prevalence of Biliary Intraepithelial Neoplasia (BilIN) in laparoscopic cholecystectomies: clinical, surgical, and histopathological associations
Authors & Institutions
du Plessis, Maria C.; Ramburger, Micaela A.; Varela, José R.; Quesada, Bernabé M.; Baglietto, Nicolas F.; Comodo Oriana B.; Canullan, Carlos M.; Zandalazini, Hugo I.; Petracchi, Enrique J.
Division of General Surgery, Hospital General de Agudos Dr. Cosme Argerich, Pi y Margall 750, C1155AHD, Autonomous City of Buenos Aires, Buenos Aires, Argentina.
Background
The aim of this study was to determine the prevalence of BilIN and evaluate its association with clinical, surgical, and histopathological variables in a cohort of laparoscopic cholecystectomies.
Method
A retrospective observational analytical study was conducted including all consecutive LC performed between January 2018 and December 2025 at a tertiary referral center. Clinical, surgical, postoperative, and histopathological variables were analyzed. Patients were divided according to the presence or absence of BilIN. An exploratory analysis comparing low-grade and high-grade BilIN was also performed.
Results
Among 2604 LC, BilIN was identified in 56 patients (2.1%), including 42 low-grade (1.6%) and 14 high-grade lesions (0.5%). Chronic cholecystitis was present in 54 (96.4%) with BilIN. Patients without BilIN presented a significantly higher frequency of cystic duct stones and complicated biliary disease. No significant differences in operative variables, morbidity, or conversion rates. Associated carcinoma was in 3 patients with BilIN (5.4%), all corresponding to high-grade lesions (21.4% vs 0%, p = 0.013). All carcinomas were incidental early-stage well-differentiated adenocarcinomas.
Conclusion
BilIN was identified in 2.1% of LC specimens. High-grade BilIN showed a significant association with incidental gallbladder carcinoma, supporting its role as a relevant precursor lesion in gallbladder carcinogenesis.
Pseudotumoral versus incidental xanthogranulomatous cholecystitis: a comparative analysis of operative complexity and outcomes after laparoscopic cholecystectomy
Authors & Institutions
du Plessis, Maria C.; Kowalski, Mariel; Varela, José R.; Quesada, Bernabé M.; Baglietto, Nicolas F.; Comodo, Oriana B.; Comodo, Oriana B.; Ovejero, Lucas R.; Canullan, Carlos M.; Zandalazini, Hugo I.; Petracchi, Enrique J.
Division of General Surgery, Hospital General de Agudos Dr. Cosme Argerich, Pi y Margall 750, C1155AHD, Autonomous City of Buenos Aires, Buenos Aires, Argentina.
Background
The aim of this study was to compare clinical characteristics, operative complexity, and perioperative outcomes between pseudotumoral and incidental forms of XGC in patients undergoing laparoscopic cholecystectomy.
Method
Retrospective analytical study of consecutive patients with histopathologically confirmed XGC undergoing cholecystectomy (2011–2025). Operative difficulty (Nassar scale), type of cholecystectomy, conversion, morbidity, bile duct injury, and length of stay were analyzed.
Results
Among 4795 laparoscopic cholecystectomies, 154 xanthogranulomatous cholecystitis cases (3.2%) were identified: 40 pseudotumoral (26%) and 114 incidental (74%). Pseudotumoral xanthogranulomatous cholecystitis was associated with acute cholecystitis, higher operative difficulty (Nassar 3 – 4), increased need for subtotal cholecystectomy, and longer operative time (p < 0.05). Conversion (3.3%), morbidity (5.8%), major complications, and bile duct injury were similar between groups.
Conclusion
Pseudotumoral xanthogranulomatous cholecystitis increases operative complexity but not adverse outcomes. Laparoscopic cholecystectomy is safe when performed using structured strategies.
Postoperative Hajibandeh Index Predicts Failure to Rescue from Post-Pancreatectomy Fistula and Haemorrhage: A 10-Year Retrospective Cohort Study
Authors & Institutions
Sophie Emma Rivett, Mariam Hussain, Sophie Gharaei, Shahin Hajibandeh, Nicola de Liguori Carino, Thomas Satyadas, Shahab Hajibandeh
Department of General and Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary Hospital, Manchester, UK
Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, UK
Background
The Hajibandeh Index (HI) considers CRP, neutrophils, lactate, albumin and lymphocytes in predicting the likelihood of peritoneal contamination and mortality in patients with acute abdominal pathology. We evaluated the predictive performance of postoperative HI for failure to rescue from clinically relevant postoperative pancreatic fistula and post-pancreatectomy haemorrhage after resection.
Method
A STROCSS-compliant retrospective cohort study (2016–2026) at a tertiary centre included 953 patients undergoing pancreaticoduodenectomy or distal pancreatectomy. The primary outcome was failure to rescue (FTR) at 30 and 90 days. Secondary outcomes were clinically relevant postop pancreatic fistula (CR-POPF), post-pancreatectomy haemorrhage (PPH), and mortality at 30 and 90 days. Predictive performance was assessed using receiver operating characteristic curve analysis.
Results
The 30-day and 90-day FTR rates were 5.1% (95% CI, 2.6%-8.6%) and 6.6% (95% CI, 3.6%-11.0%), respectively. Rates of CR-POPF, PPH, 30-day mortality, and 90-day mortality were 19.0% (95% CI, 16.6%-21.6%), 4.8% (95% CI, 3.6%-6.4%), 1.9% (95% CI, 1.2%-3.1%), and 2.7% (95% CI, 1.8%-3.9%), respectively. Day 5 HI predicted 30-day FTR (AUC, 0.74; 95% CI, 0.71-0.77), 90-day FTR (AUC, 0.74; 95% CI, 0.71-0.77), CR-POPF (AUC, 0.75; 95% CI, 0.72-0.78), PPH (AUC, 0.70; 95% CI, 0.67-0.73), 30-day mortality (AUC, 0.77; 95% CI, 0.74-0.80), and 90-day mortality (AUC, 0.75; 95% CI, 0.71-0.77).
Conclusion
Postoperative HI showed good predictive performance for FTR from fistula and haemorrhage after pancreatic resection and may help guide targeted prophylactic postoperative CT imaging.
Short-term outcomes of robotic pancreaticoduodenectomy in Western versus Eastern cohorts: a systematic review and meta-analysis
Authors & Institutions
Sophie Emma Rivett (1), Shahab Hajibandeh (1), Shahin Hajibandeh (2), Thomas Satyadas (1)
1- Department of General and Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary Hospital, Manchester, UK
2- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, UK
Background
To compare short-term outcomes after robotic pancreaticoduodenectomy between Western and Eastern cohorts.
Method
In compliance with PRISMA standards, a systematic review and meta-analysis was conducted. Studies with a minimum sample size of 100 patients reporting outcomes after robotic pancreaticoduodenectomy were included. Evaluated outcomes included operative time, severe complications (Clavien-Dindo grade ≥III), length of hospital stay (LOS), and readmission rate. Pooled estimates were calculated using a random-effects model.
Results
80 studies comprising 30,521 patients were included: 48 (20,179 patients) from the West and 32 (10,342 patients) from the East. Operative time was comparable between the West (413.9min, 95% CI:397.3–430.5) and East (366.3min, 95% CI:330.8–401.7). There was no difference in Clavien-Dindo ≥III complications between the West (24.9%, 95% CI:19.6-30.1) and East (19.5%, 95% CI:15.7-23.4). LOS was shorter in the West (9.6 days, 95% CI:9.0-10.2) than the East (17.1 days, 95% CI:15.5-18.6); readmission rate was higher in the West (18.4%, 95% CI:15.7-21.0) compared to the East (6.3%, 95% CI:5.1-7.5).
Conclusion
Severe morbidity after robotic pancreaticoduodenectomy is comparable between the West and East. Shorter LOS in Western countries comes at the expense of a significantly higher readmission rate, suggesting frequent readmissions may be the direct trade-off of early discharge practices in this setting.
Group & screen in elective laparoscopic cholecystectomy: is it really needed?
Authors & Institutions
Sophie Emma Rivett (1), Shahab Hajibandeh (1), Shahin Hajibandeh (2), Thomas Satyadas (1)
1- Department of General and Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary Hospital, Manchester, UK
2- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, UK
Background
To compare short-term outcomes after robotic pancreaticoduodenectomy between Western and Eastern cohorts.
Method
In compliance with PRISMA standards, a systematic review and meta-analysis was conducted. Studies with a minimum sample size of 100 patients reporting outcomes after robotic pancreaticoduodenectomy were included. Evaluated outcomes included operative time, severe complications (Clavien-Dindo grade ≥III), length of hospital stay (LOS), and readmission rate. Pooled estimates were calculated using a random-effects model.
Results
80 studies comprising 30,521 patients were included: 48 (20,179 patients) from the West and 32 (10,342 patients) from the East. Operative time was comparable between the West (413.9min, 95% CI:397.3–430.5) and East (366.3min, 95% CI:330.8–401.7). There was no difference in Clavien-Dindo ≥III complications between the West (24.9%, 95% CI:19.6-30.1) and East (19.5%, 95% CI:15.7-23.4). LOS was shorter in the West (9.6 days, 95% CI:9.0-10.2) than the East (17.1 days, 95% CI:15.5-18.6); readmission rate was higher in the West (18.4%, 95% CI:15.7-21.0) compared to the East (6.3%, 95% CI:5.1-7.5).
Conclusion
Severe morbidity after robotic pancreaticoduodenectomy is comparable between the West and East. Shorter LOS in Western countries comes at the expense of a significantly higher readmission rate, suggesting frequent readmissions may be the direct trade-off of early discharge practices in this setting.
