Health-related quality of life in patients undergoing laparoscopic versus open hemihepatectomy: a secondary analysis of the ORANGE II PLUS randomised controlled, phase 3, superiority trial

Background

Health-related quality of life (HRQoL) has become a critical factor in determining the benefits of new surgical approaches on patients. The ORANGE II PLUS randomised trial compared laparoscopic (LH) and open (OH) hemihepatectomy in an international multicentre randomised controlled setting, with HRQoL as a secondary outcome. The aim of this study was to perform an in-depth analysis of the HRQoL outcomes.

Methods

Between October 2013 and January 2019, 352 patients scheduled for hemihepatectomy, were randomly assigned to either LH or OH in a 1:1-ratio in 16 European centres. HRQoL was assessed using the EORTC-QLQ-C30 and QLQ-LMC21 modules, at baseline, hospital discharge, and at 10-days, 3-, 6-, and 12-months after discharge. Differences in functioning- and five selected symptom scales were compared between LH and OH over the cumulative periods from discharge to 3 months as well as to 12 months using a multivariable adjusted linear mixed regression model. The study was registered at ClinicalTrials.gov (NCT01441856).

Findings

The modified intention-to-treat analysis included 332 patients (166 LH and 166 OH), with 40% female in LH and 42% female in OH. 1546 questionnaires (81% of maximum) were obtained. Cumulatively over the period from discharge to 3 months postoperatively, patients in the laparoscopic group reported better physical (difference 4.20 points; 95% CI 1.07-7.34) and social functioning (5.95 points; 95% CI 1.65-10.26), and lower pain (-6.41 points, 95% CI -10.01 to -2.82) and appetite loss (-7.29 points, 95% CI -11.59 to -2.99), compared to the OH group. Similar clinically relevant, but slightly attenuated, differences were reported over the cumulative period from discharge to 12 months after surgery. The largest difference was observed at 10 days after surgery.

Interpretation

In this international randomised trial evaluating HRQoL, LH demonstrated better physical and social functioning, and less pain and appetite loss, compared to OH. These findings support the preferential use of the laparoscopic approach for hemihepatectomy in experienced centres.

Funding

Maastricht University Medical Centre+, University Hospital RWTH Aachen, Cancer Research UK 12/048, European Association of Endoscopic Surgery, participating centres.

Advanced gallbladder cancer (T3 and T4): insights from an international multicenter study

BACKGROUND

Surgical resection is the only curative treatment of gallbladder cancer (GBC). However, the role of oncologic extended resection (OER) in advanced GBC (T3/T4) remains unclear. This study aimed to evaluate the effect of OER in patients with advanced GBC.

METHODS

This retrospective, multicenter study analyzed 419 patients diagnosed with GBC at 17 institutions across 7 countries between 1997 and 2022. Adjusted logistic regression was used to examine factors affecting R1 resection and lymph node positivity. Survival was assessed using Kaplan-Meier curves and multivariate Cox proportional hazards.

RESULTS

Of the cohort, 369 patients with T3 GBC and 50 patients with T4 GBC were identified. Predictors of R1 status for patients with T3/T4 GBC included jaundice before surgery (odds ratio [OR], 3.03 [95% CI, 1.68-5.45]), perineural and/or lymphovascular invasion (OR, 2.43 [95% CI, 1.35-4.39]), adjacent organ resection (OR, 2.05 [95% CI, 1.09-3.85]), overall morbidity (OR, 1.64 [95% CI, 1.01-2.66]), and lymph node metastasis (OR, 2.69 [95% CI, 1.55-4.66]). Morbidity was higher in patients (64.8%) with T4 GBC than in patients (38.2%) with T3 GBC, with severe morbidity at 46.3% and 17.1%, respectively. Of note, 90-day mortality was 4.1% for patients with T3 GBC and 12% for patients with T4 GBC. The 3-year overall survival rate was 33% for patients with T3 GBC and 4% for patients with T4 GBC (log-rank P <.001).

CONCLUSION

Advanced-stage GBC outcomes vary with resection status. OER is associated with increased morbidity, particularly in patients with T4 GBC, for whom survival benefits are limited. Careful patient selection for aggressive surgical treatment is crucial to avoid unnecessary morbidity while carefully weighing the potential survival benefits.

Analysis of the best time-point for 18F-FDG PET/CT delayed imaging in patients of small colorectal cancer liver metastasis with hypothyroidism based on diagnostic efficacy and image standardized uptake values

OBJECTIVE

This study analyzes the role of positron emission tomography/computed tomography (PET/CT) in the diagnosis of small (< 10 mm) colorectal cancer liver metastasis (CRLM) lesions in patients with hypothyroidism. In particular, the impact of the best time for delayed imaging on improving diagnostic efficacy.

METHODS

We retrospectively analyzed 231 patients with small CRLM lesions with hypothyroidism who underwent dual time-point 18F-FDG PET/CT imaging. Based on the previous studies and clinical practice experience, 120-190 min was selected as the time range for delayed imaging, divided into eight teams in 10-min groups. The delayed images of the eight time periods were first analyzed and compared for diagnostic efficacy, and second analyzed and compared for standardized uptake value (SUV) and of PET/CT images to observe the trend of SUV values over time.

RESULTS

The results of diagnostic efficacy analysis indicated that the 180-min delay group had the highest diagnostic efficacy (sensitivity, specificity, and accuracy). Comparison of the SUV values with the delay time analysis showed that maximum standardized uptake value (SUVmax) increased with the delay time, and the normal liver tissue (SUVmean) decreased with the delay time, which resulted in the gradual increase in the ratio of the lesion to the normal liver tissue (TNR). By selecting the time-point with the highest TNR ratio and stable SUV value, and combining the results of diagnostic efficacy, this study successfully verified the best imaging time-point. After comprehensive consideration, 180 min was determined as the best imaging time-point, when the TNR reached the highest, the SUV value was stable, and the diagnostic efficacy was best.

CONCLUSIONS

In this study, the impact of delayed imaging on the diagnostic efficacy and SUV value of PET/CT images in patients of small CRLM with hypothyroidism was shown intuitively, and the changing pattern of SUV at different time points was also observed. The best time-point for PET/CT delayed imaging was determined to be 180 min, which provides a new scanning program for the diagnosis in patients of small CRLM with hypothyroidism.

Post-reperfusion syndrome in liver transplant recipients: What is new in prevention and management?

Post-reperfusion syndrome (PRS) in liver transplant recipients remains one of the most dreaded complications in liver transplant surgery. PRS can impact the short-term and long-term patient and graft outcomes. The definition of PRS has evolved over the years, from changes in arterial blood pressures and heart and/or decreases in the systemic vascular resistance and cardiac output to including the fibrinolysis and grading the severity of PRS. However, all that did not reflect on the management of PRS or its impact on the outcomes. In recent years, new scientific techniques and new technology have been in the pipeline to better understand, manage and maybe prevent PRS. These new methods and techniques are still in the infancy, and they have to be proven not in prevention and management of PRS but their effects in the patient and graft outcomes. In this article, we will review the long history of PRS, its definition, etiology, management and most importantly the new advances in science and technology to prevent and properly manage PRS.

Revolutionizing hepatobiliary surgery: Impact of three-dimensional imaging and virtual surgical planning on precision, complications, and patient outcomes

BACKGROUND

Hepatobiliary surgery is complex and requires a thorough understanding of the liver’s anatomy, biliary system, and vasculature. Traditional imaging methods such as computed tomography (CT) and magnetic resonance imaging (MRI), although helpful, fail to provide three-dimensional (3D) relationships of these structures, which are critical for planning and executing complicated surgeries.

AIM

To explore the use of 3D imaging and virtual surgical planning (VSP) technologies to improve surgical accuracy, reduce complications, and enhance patient recovery in hepatobiliary surgeries.

METHODS

A comprehensive review of studies published between 2017 and 2024 was conducted through PubMed, Scopus, Google Scholar, and Web of Science. Studies selected focused on 3D imaging and VSP applications in hepatobiliary surgery, assessing surgical precision, complications, and patient outcomes. Thirty studies, including randomized controlled trials, cohort studies, and case reports, were included in the final analysis.

RESULTS

Various 3D imaging modalities, including multidetector CT, MRI, and 3D rotational angiography, provide high-resolution views of the liver’s vascular and biliary anatomy. VSP allows surgeons to simulate complex surgeries, improving preoperative planning and reducing complications like bleeding and bile leaks. Several studies have demonstrated improved surgical precision, reduced complications, and faster recovery times when 3D imaging and VSP were used in complex surgeries.

CONCLUSION

3D imaging and VSP technologies significantly enhance the accuracy and outcomes of hepatobiliary surgeries by providing individualized preoperative planning. While promising, further research, particularly randomized controlled trials, is needed to standardize protocols and evaluate long-term efficacy.

Artificial intelligence in gastrointestinal surgery: A minireview of predictive models and clinical applications

BACKGROUND

Artificial intelligence (AI) is playing an increasingly significant role in predicting outcomes of gastrointestinal (GI) surgeries, improving preoperative risk assessment and post-surgical decision-making. AI models, particularly those based on machine learning, have demonstrated potential in predicting surgical complications and recovery trajectories.

AIM

To evaluate the role of AI in predicting outcomes for GI surgeries, focusing on its efficacy in enhancing surgical planning, predicting complications, and optimizing post-operative care.

METHODS

A systematic review of studies published up to March 2025 was conducted across databases such as PubMed, Scopus, and Web of Science. Studies were included if they utilized AI models for predicting surgical outcomes, including morbidity, mortality, and recovery. Data were extracted on the AI techniques, performance metrics, and clinical applicability.

RESULTS

Machine learning models demonstrated significantly better performance than logistic regression models, with an area under the curve difference of 0.07 (95%CI: 0.04–0.09; P < 0.001). Models focusing on variables such as patient demographics, nutritional status, and surgical specifics have shown improved accuracy. AI’s ability to integrate multifaceted data sources, such as imaging and genomics, contributes to its superior predictive power. AI has improved the early detection of gastric cancer, achieving 95% sensitivity in real-world settings.

CONCLUSION

AI has the potential to transform GI surgical practices by offering more accurate and personalized predictions of surgical outcomes. However, challenges related to data quality, model transparency, and clinical integration remain.

Liver transplantation in patients with neurological Wilson disease: What can a five-decade systematic literature review teach us?

BACKGROUND

Neurological worsening occurs in up to 20 % of patients with Wilson disease and neurological involvement (neuroWD) despite optimal anti‑copper therapy. This study aimed to analyze the neurological outcomes of patients with neuroWD who underwent liver transplantation (LT) as a rescue therapy for neurological deterioration (Brain group), and to compare them with those who underwent LT for end-stage liver disease (ESLD) (Liver group).

METHODS

A systematic PubMed search identified studies on neuroWD and LT published from January 1973 to January 2024.

RESULTS

A total of 368 patients with neuroWD were identified, including 89 and 279 in the Brain and Liver groups, respectively. Post-LT survival rates were similar between groups (82 % vs. 86.6 %). Sepsis was the primary cause of death in both groups (68.7 % in the Brain group vs. 57.1 % in the Liver group). Among survivors beyond 1 year, 86.3 % in the Brain group and 79.7 % in the Liver group showed improvement or complete recovery from neuroWD. De novo post-LT neurological complications and calcineurin inhibitors-induced neurotoxicity were reported exclusively in the Liver group (p < 0.05).

CONCLUSION

LT is a viable option for neuroWD unresponsive to medical therapy. Delayed introduction or early minimization of calcineurin inhibitors is recommended for ESLD patients to reduce neurotoxicity. Further studies are needed to confirm these observations, as there are currently no evidence-based medicine criteria or standardized inclusion scales for LT in cases of neuro-WD.

Multicystic biliary hamartoma with long-term gradual enlargement treated by laparoscopic partial hepatectomy

Multicystic biliary hamartoma (MCBH) is an extremely rare liver tumor characterized by a well-circumscribed, multicystic honeycomb appearance on imaging. Herein, we report a case of long-term gradually enlarging MCBH that underwent laparoscopic hepatectomy. A 69-year-old man presented with mildly elevated carcinoembryonic antigen levels and underwent computed tomography (CT) 11 and 5 years ago, at which time the physicians did not note any particular abnormal findings. The current contrast CT for screening demonstrated a cystic lesion in segment 2 of the liver. A retrospective review of CT images showed that the cystic lesion had gradually increased over time. The patients successfully underwent laparoscopic partial hepatectomy and recovered without any complications. The surgically resected specimen grossly presented an aggregated nodule of small cysts. Pathological findings showed multiple cysts of various sizes covered with cuboidal cells without dysplasia resembling bile duct epithelium, with lumens containing a stone component consisting of brown bile. Around the cyst, there was vascular fibrous tissue, smooth muscle bundles, normal hepatocytes, and chronic inflammation. Based on these findings, we finally diagnosed MCBH. Although MCBH is histologically classified as a benign tumor, physicians may have to pay careful attention to the potential for enlargement in actual clinics.

Beta-catenin/sirtuin 1/farnesoid X receptor pathway promotion of portal vein ligation and parenchymal transection-induced rapid liver regeneration

BACKGROUND

By accelerating the regeneration of the future liver remnant, portal vein ligation and parenchymal transection allows for more extensive hepatectomy. Given that the mechanism remains poorly understood, the aim of this study was to investigate the mechanism of portal vein ligation and parenchymal transection-induced liver regeneration.

METHODS

A portal vein ligation and parenchymal transection-induced liver regeneration mouse model was established, followed by RNA microarray analysis to identify candidate molecules. Genomic deletion and chemical manipulation of target molecules were used to explore their functions in portal vein ligation and parenchymal transection-induced liver regeneration. Validation was conducted using a diseased liver model and human samples.

RESULTS

Portal vein ligation and parenchymal transection-induced liver regeneration was significantly accelerated compared with that in sham-operated mice (P < .05). An RNA microarray revealed that Sirtuin 1 is a crucial molecule in the proliferation of the future liver remnant. Regardless of whether Sirtuin 1 is inhibited chemically or through genetic deletion, portal vein ligation and parenchymal transection-induced liver regeneration is distinctly attenuated. Further investigation revealed that Sirtuin 1 promoted portal vein ligation and parenchymal transection-induced liver regeneration via the farnesoid X receptor. In addition, beta-catenin also was found to participate in the process of future liver remnant proliferation. Chemical inhibition of beta-catenin markedly impaired but activation of WNT/beta-catenin mildly enhanced portal vein ligation and parenchymal transection-induced liver regeneration (P < .05). Deletion of Sirtuin 1 blocked the facilitating effect of beta-catenin on portal vein ligation and parenchymal transection-induced liver regeneration. These findings were validated in diseased liver models and patient samples, confirming the correlation between the beta-catenin/Sirtuin 1/farnesoid X receptor pathway and portal vein ligation and parenchymal transection-induced liver regeneration.

CONCLUSION

Activation of the beta-catenin/Sirtuin 1/farnesoid X receptor pathway offers critical mechanistic insights into accelerating portal vein ligation and parenchymal transection-induced liver regeneration. Modulation of beta-catenin/Sirtuin 1/farnesoid X receptor may therefore improve clinical outcomes in patients receiving staged hepatectomy.

Liver metastases from colorectal cancer: A joint ESSO-EAHPBA-UEMS core curriculum collaboration

Colorectal liver metastases (CRLM) are a major indication for liver surgery in Europe, highlighting the need for standardized knowledge and training in surgical oncology. The European Society of Surgical Oncology (ESSO) has updated its core curriculum to provide a structured framework for education. Previous publications have addressed pancreatic, hepatocellular, and biliary tract cancers to support candidates preparing for the European Board of Surgery Qualification (EBSQ) exams in Surgical Oncology and Hepato-Pancreato-Biliary Surgery. However, a dedicated guide for CRLM remains absent. This article aims to fill that gap by offering a structured reference on CRLM, covering epidemiology, staging, genetics, and diagnosis of metastatic colorectal cancer. It also outlines multidisciplinary treatment strategies, including systemic, surgical, interventional, and palliative approaches. A structured literature review was conducted using PubMed to identify the most updated (inter)national management guidelines, prioritizing recent multicentre studies, systematic reviews, and meta-analyses published from January 2020 to January 2025. By bridging the gap between the ESSO core curriculum and detailed subspecialty training, this guide provides an essential resource for hepatobiliary surgeons and surgical oncologists. It serves as a valuable tool for those preparing for board examinations while promoting a standardized approach to CRLM education and management across Europe.

Anesthetic Considerations for Robotic Liver Transplantation

Liver transplantation has traditionally been performed through a large, bilateral subcostal incision. Recently, liver transplant programs across the world, including our own, have reported successful liver transplants via total robotic approaches on recipients with low Model for End-stage Liver Disease scores and preexisting abdominal wall laxity. This review discusses the unique anesthetic considerations of robotic liver transplantation based on our group's initial experience with this novel surgical approach. Robotic liver transplantation presents a unique set of considerations and challenges for the anesthesiologist, and a thorough understanding of liver disease, liver transplant surgery, venovenous bypass, and the various implications of robotic surgery is essential to ensure optimal patient outcomes. Specific management topics discussed here include appropriate patient selection, preoperative assessment, and intraoperative management. We also discuss certain theoretical and actual challenges that our group has experienced.

Validation of the Iwate scoring system for the stratification of laparoscopic liver resections: An international multicenter study

INTRODUCTION

The Iwate difficulty scoring system (DSS) is one of the most widely validated DSS for laparoscopic liver resection (LLR). However, these studies only validated the 4 difficulty levels and did not validate the 12-point difficulty index of the system. To address current limitations in the studies validating the Iwate difficulty scoring system (DSS), we performed an international multicenter study to validate the Iwate DSS across both its four difficulty levels and 12-point difficulty index.

METHODS

A retrospective cohort study of 22,252 patients undergoing LLR across 64 centers worldwide between 2005 and 2021 was performed. Baseline characteristics and perioperative outcomes were analyzed across the four difficulty levels and 12-point difficulty index of the Iwate DSS.

RESULTS

A total of 14,759 patients met the inclusion criteria. The main indications for LLR were hepatocellular carcinoma/intrahepatic cholangiocarcinoma (52.8 %), and metastatic tumors liver (26.5 %). In terms of underlying liver pathology, 5127 patients (34.8 %) had liver cirrhosis, and 1214 patients (8.3 %) had portal hypertension. Intraoperative outcomes (operation time, blood loss, blood transfusion, use of Pringles maneuver and open conversion) and postoperative outcomes (length of stay, morbidity, major complications, and 90-day mortality) significantly increased with stepwise increases across the four difficulty levels (P < 0.001) and 12-point difficulty index (P < 0.001). These trends remained significant following adjustment for baseline characteristics (P < 0.001).

CONCLUSION

The Iwate DSS 12-point difficulty index and four difficulty levels correlated well with LLR difficulty as determined by key surrogate perioperative measures.

Development and validation of a nomogram to predict the need for bailout procedure in laparoscopic cholecystectomy: A multicenter study of 1,898 cases

BACKGROUND

Laparoscopic cholecystectomy is the standard treatment for benign gallbladder disease. A bailout procedure is recommended for patients with severe inflammation. This study identified the preoperative factors that predict bailout procedures and developed a predictive nomogram.

METHODS

A total of 1,898 patients with laparoscopic cholecystectomy from 5 institutions (2015-2020) were divided into training (n = 1,518) and validation (n = 380) sets. Logistic regression was employed to predict bailout procedures and to develop a nomogram on the basis of the training set. The accuracy of the nomogram was evaluated using receiver operating characteristic curve analysis of the validation set. Postoperative outcomes were compared between qualified surgeons certified by the Japanese Society for Endoscopic Surgery and residents who had graduated from a medical university within the past 5 years.

RESULTS

Bailout procedures were performed in 262 (13.8%) patients. Multivariate analysis identified several significant predictors, including sex, age, gallbladder drainage, severity of acute cholecystitis, stone impaction of the gallbladder neck, and serum C-reactive protein. The nomogram achieved an area under the curve of 0.788 in the training set and 0.769 in the validation set. Intraoperative complications were significantly fewer in the qualified surgeon group than in the nonqualified surgeon group.

CONCLUSION

The nomogram aids surgeons in identifying high-risk patients and making informed decisions about bailout procedures, thereby ensuring patient safety. Involving qualified surgeons in case predicted to be difficult cholecystectomies may help prevent help to avoid intraoperative complications.

What matters in laparoscopic hepatectomy for lesions located in posterosuperior segments? Initial experiences and analysis of risk factors for postoperative complications: a retrospective cohort study

BACKGROUND

Laparoscopic liver resection (LLR) for lesions in the posterosuperior segments (PSS) is challenging. Identifying and minimizing risk factors for postoperative morbidity and mortality is crucial. This retrospective cohort study shares initial experiences with LLR of the PSS (VII, VIII, IVa) and wants to identify risk factors for clinically relevant postoperative complications (Clavien-Dindo grade ≥ III) in these patients.

METHODS

We reviewed our prospective database for all patients who underwent LLR with at least one lesion in the PSS (April 2018-October 2022). Uni- and multivariate analyses were carried out using binary logistic regression analysis.

RESULTS

110 patients underwent LLR of the PSS. Median age was 67 years (IQR 59-76); 62% were male (n = 68), with a median BMI of 26 (IQR 23-30). The most frequent indications for LLR were primary liver cancer (37%) and colorectal liver metastasis (36%). Median operating time was 211 min (IQR 135-281) with a median blood loss of 460 mL (IQR 240-1200). Postoperative length of stay was 6 days (IQR 4-8). Clinically relevant postoperative complications were present in 20 patients (18%) with a 90-day mortality rate of 5% (n = 6). Multivariate analyses identified ASA ≥ III (OR 3.23 [95%CI 1.03-10.09]; p = 0.043), diabetes (OR 4.31 [95%CI 1.20-15.49]; p = 0.025), and intraoperative transfusion of packed red blood cells (PRBC) (OR 4.80 [95%CI 1.01-22.86]; p = 0.049) as risk factors for Clavien-Dindo grade ≥ III complications.

CONCLUSION

ASA ≥ III status, diabetes, and intraoperative PRBC transfusion are associated with an increased risk of Clavien-Dindo grade ≥ III complications in patients undergoing LLR in PSS. Preoperative optimization should include diabetes management, screening for anemia with appropriate supplementation, and comprehensive risk counseling for ASA ≥ III patients. Additionally, minimizing intraoperative PRBC transfusion should remain a key perioperative goal.

Liver transplantation for primary and secondary liver tumors: Patient-level meta-analyses compared to UNOS conventional indications

BACKGROUND AND AIMS

Liver transplant (LT) for transplant oncology (TO) indications is being slowly adopted worldwide and has been recommended to be incorporated cautiously due to concerns about mid-long-term survival and its impact on the waiting list.

APPROACH AND RESULTS

We conducted 4 systematic reviews of all series on TO indications (intrahepatic cholangiocarcinoma and perihilar cholangiocarcinoma [phCC]) and liver metastases from neuroendocrine tumors (NETs) and colorectal cancer (CRLM) and compared them using patient-level meta-analyses to data obtained from the United Network for Organ Sharing (UNOS) database considering conventional daily-practice indications. Secondary analyses were done for specific selection criteria (Mayo-like protocols for phCC, SECA-2 for CRLM, and Milan criteria for NET). A total of 112,014 LT were analyzed from 2005 to 2020 from the UNOS databases and compared with 345, 721, 494, and 103 patients obtained from meta-analyses on intrahepatic cholangiocarcinoma and phCC, and liver metastases from NET and CRLM, respectively. Five-year overall survival was 53.3%, 56.4%, 68.6%, and 53.8%, respectively. In Mantel-Cox one-to-one comparisons, survival of TO indications was superior to combined LT, second, and third LT and not statistically significantly different from LT in recipients >70 years and high BMI.

CONCLUSIONS

Liver transplantation for TO indications has adequate 5-year survival rates, mostly when performed under the selection criteria available in the literature (Mayo-like protocols for phCC, SECA-2 for CRLM, and Milan for NET). Despite concerns about its impact on the waiting list, some other LT indications are being performed with lower survival rates. These oncological patients should be given the opportunity to have a definitive curative therapy within validated criteria.

Postoperative hepatic insufficiency despite preoperative portal vein embolization: Not just about the volumetrics

BACKGROUND

Future liver remnant hypertrophy is the primary endpoint of portal vein embolization before major hepatectomy. However, even when adequate future liver remnant is achieved, postoperative hepatic insufficiency is not universally averted. We aimed to identify preoperative risk factors of postoperative hepatic insufficiency despite the use of portal vein embolization.

METHODS

Patients who underwent portal vein embolization followed by major hepatectomy at 6 academic medical centers were retrospectively reviewed. Postoperative hepatic insufficiency was defined as postoperative peak bilirubin >7 mg/dL. Preoperative variables associated with postoperative hepatic insufficiency were analyzed.

RESULTS

From 2008 to 2019, 164 patients underwent portal vein embolization followed by major hepatectomy. Twenty (12%) patients developed postoperative hepatic insufficiency. On univariate analysis, postoperative hepatic insufficiency was associated with older age, performance status, preoperative biliary drainage, smaller pre- and post-portal vein embolization future liver remnant volumes, diagnosis of cholangiocarcinoma/gallbladder cancer, and preoperative cholangitis. There was significant future liver remnant hypertrophy noted even in the setting of postoperative hepatic insufficiency (from 27% to 39%); however, degree of hypertrophy >5% (100% vs 93%, P = .6) and kinetic growth rate >2%/week (95% vs 82%, P = .3) did not differ between the postoperative hepatic insufficiency and non-postoperative hepatic insufficiency groups. On multivariate analysis, the diagnosis of cholangiocarcinoma/gallbladder cancer and preoperative cholangitis (postoperative hepatic insufficiency incidence 34% and 62%, respectively), but not future liver remnant volumetrics, were independently associated with postoperative hepatic insufficiency. Postoperative hepatic insufficiency raised post-hepatectomy 90-day mortality from 3.5% to 45% and hospitalization from 7 days to 16 days (both P < .001).

CONCLUSION

Postoperative hepatic insufficiency still occurs in 12% of patients after major hepatectomy despite preoperative portal vein embolization. In addition to traditional volumetric information, surgeons should be aware of preoperative cholangitis and cholangiocarcinoma/gallbladder cancer as powerful predictors of this fatal complication.

Biliary tract cancer

BACKGROUND

Biliary tract cancers comprise a heterogeneous collection of malignancies usually described as cholangiocarcinoma of the intra- or extrahepatic bile duct, including perihilar cholangiocarcinoma and gallbladder cancer.

METHODS

A review of pertinent parts of the ESSO core curriculum for the UEMS diploma targets (Fellowships exam, EBSQ), based on updated and available guidelines for diagnosis, surgical treatment and oncological management of cholangiocarcinoma.

RESULTS

Following the outline from the ESSO core curriculum we present the epidemiology and risk factors for cholangiocarcinoma, as well as the rationale for the current diagnosis, staging, (neo-)adjuvant treatment, surgical management, and short- and long-term outcomes. The available guidelines and consensus reports (i.e. NCCN, BGS and ESMO guidelines) are referred to. Recognition of biliary tract cancers as separate entities of the intrahepatic biliary ducts, the perihilar and distal bile duct as well as the gallbladder is important for proper management, as they each provide distinct clinical, molecular and treatment profiles to consider.

CONCLUSION

Core competencies in knowledge to the diagnosis, management and outcomes of biliary tract cancers are presented.

A nomogram for predicting early biliary complications in adult liver recipients of deceased donor grafts: Integrating artery resistive index and clinical risk factors

BACKGROUND

This study aimed to identify predictors of biliary complications within 90 days after liver transplantation in adult recipients of deceased donor grafts.

METHODS

The study retrospectively analyzed adult patients who underwent liver transplantation from January 2016 to December 2021 using deceased donor grafts in our center. Patients were randomly divided into training and validation cohorts (7:3 ratio). A nomogram was developed using least absolute shrinkage and selection operator logistic regression for feature selection, followed by a 2-way stepwise approach in multivariate logistic regression. Model performance was assessed with the C-index, receiver operating characteristic area under the curve, calibration curves, and decision curve analysis.

RESULTS

A total of 757 patients were included, of whom 76 developed early biliary complications. Least absolute shrinkage and selection operator binary logistic analysis showed that postoperative day 1 arterial resistance index, acute rejection, acute-on-chronic liver failure, hepatic artery thrombosis, recipient body mass index, and donor age were independent predictors of biliary complications within 90 days. A nomogram was established on the basis of these factors. The C-index for the final nomogram was 0.822. The area under the curve in the training cohort was 0.837 (95% confidence interval, 0.780-0.893) and 0.771 (95% confidence interval, 0.677-0.865) in the validation cohort. Calibration curves demonstrated good agreement between predicted and actual outcomes. Decision curve analysis confirmed the clinical utility of the nomogram.

CONCLUSION

Low arterial resistance index (≤0.57) on the first postoperative day is a predictor of biliary complications within 90 days after liver transplantation in adult recipients of deceased donor grafts. The nomogram provides a practical tool for predicting complications and guiding clinical decisions.

Improved Outcomes Following Resection of Perihilar Cholangiocarcinoma: A 27-Year Experience

BACKGROUND

Resection of perihilar cholangiocarcinoma (pCCA) is associated with significant perioperative morbidity and mortality. We sought to evaluate surgical outcomes following resection of pCCA over time.

METHODS

Patients who underwent curative-intent resection with hepatectomy for pCCA at a single institution were divided into two cohorts based on date of resection: past cohort (1996-2013), and recent cohort (2014-2023).

RESULTS

The study included 100 patients: 55 (55%) in the past (1996-2013) and 45 (45%) in the recent (2014-2023) cohorts. There were no differences between cohorts in age, sex, or Bismuth-Corlette classification between the two cohorts. Preoperative cholangitis was less common in the recent cohort (31% vs. 53%, p = 0.03). The proportions of right and left hepatectomies were similar in both cohorts. However, for patients with Bismuth-Corlette types I, II, and IV tumors (n = 35), left hepatectomy was more frequently performed in the recent cohort (61% vs. 13%, p = 0.005). There were trends toward lower rates of major complications (38% vs. 55%, p = 0.095) in the recent cohort. There was significantly less perioperative mortality (2% vs. 15%, p = 0.039) and no postoperative hepatic insufficiency in the recent cohort (0% vs. 20%, p = 0.001). Median recurrence-free survival was similar in the past and recent cohorts (29 vs. 37 months, respectively; p = 0.560), but median overall survival was improved in the recent cohort (33 months vs. not reached, p = 0.009).

CONCLUSIONS

Perioperative management to reduce preoperative cholangitis and liver insufficiency, advances in surgical technique, and consideration of left-sided hepatic resection have resulted in significantly improved outcomes in patients undergoing hepatectomy for pCCA.

Prognostic significance of the cachexia index for patients with perihilar cholangiocarcinoma

BACKGROUND

The prognostic value of the preoperative cachexia index for patients with perihilar cholangiocarcinoma remains unclear.

METHODS

We retrospectively evaluated 236 patients who underwent radical resection for perihilar cholangiocarcinoma from September 2002 to December 2020. The cachexia index was calculated as follows: (skeletal muscle index × albumin level)/neutrophil-to-lymphocyte ratio, with sex-specific cutoff values determined via receiver operating characteristic curves on the basis of 3-year survival data. Clinicopathologic characteristics and survival outcomes were compared between the low-cachexia index (n = 95) and high-cachexia index (n = 141) groups. Multivariable analyses were performed to identify prognostic factors for overall survival and relapse-free survival.

RESULTS

The low-cachexia index group was characterized by greater carbohydrate antigen 19-9 level (56 vs 31 U/mL, P = .024) and greater proportion of preoperative biliary drainage (84% vs 70%, P = .013). The low-cachexia index group underwent vascular resection and reconstruction more frequently (47% vs 29%, P = .006) and had a greater rate of lymph node metastasis (54% vs 35%, P = .005). The median overall survival and relapse-free survival times of the low-cachexia index group were significantly worse than those of the high-cachexia index group (overall survival, 29.0 vs 47.4 months, P < .001; relapse-free survival, 17.2 vs 33.1 months, P < .001). Multivariable analysis revealed that a preoperative cachexia index (hazard ratio for overall survival, 0.95, P = .008; hazard ratio for relapse-free survival, 0.95, P = .017) and high preoperative carbohydrate antigen 19-9 level (hazard ratio for overall survival, 1.01, P = .002; hazard ratio for relapse-free survival, 1.01, P = .012) were prognostic factors.

CONCLUSION

The cachexia index may be a useful biomarker for the prediction of tumor aggressiveness and prognosis before perihilar cholangiocarcinoma resection.

Defining benchmark values for outcomes of comprehensive resection of primary retroperitoneal liposarcoma: a retrospective multicenter study

Background

Comprehensive resection represents the standard of care for patients affected by retroperitoneal well- or dedifferentiated liposarcoma (WDLPS/DDLPS). However, reference values to indicate the best achievable results are currently lacking. As such, the study aimed to define clinically relevant benchmark values for intra- and postoperative outcomes of patients undergoing comprehensive resection for primary retroperitoneal WDLPS/DDLPS.

Methods

The international, prospectively maintained Retroperitoneal Sarcoma Registry (RESAR; NCT03838718) was used to calculate benchmark values for 22 outcomes, including intraoperative factors, and rates of complications, recurrence and survival. Only low-risk patients undergoing comprehensive resection for WDLPS/DDLPS at high-volume centers between 1st January 2017 and 31st December 2021 were used to calculate the benchmark values. Specifically, "low risk" was defined as age <75 years, with minimal comorbidities, and undergoing a "standard" comprehensive resection including at least colon and kidney with or without other organs-excluding those associated with significant morbidity (e.g., pancreas). Benchmark values were defined based on the 25th or 75th percentiles of the center-level data. To validate the benchmark values, these were applied to two cohorts expected to have inferior outcomes, which were defined by changing one of the exclusion criteria; namely those treated in low-volume centers, and those with American Society of Anesthesiologists (ASA) score ≥3 ("ASA ≥ 3").

Findings

Of the 1510 patients undergoing surgery, 147 met the inclusion criteria and were included in the benchmarking analysis. This identified benchmark values including: median duration of surgery ≤278 min, intraoperative packed red cell transfusion rate ≤30%, R0/R1 resection rate ≥89%, median length of hospital stay ≤15 days, reoperation rate ≤13%, major postoperative complication rate ≤21%, and 90-day postoperative mortality/failure-to-rescue rates of 0%. The "low-volume centers" cohort failed to meet 10 of these benchmarks, including duration of surgery (median: 293 vs. ≤278 min), R0/R1 resection rate (82% vs. ≥ 89%), major postoperative complication rate (35% vs. ≤21%), and reoperation rate (35% vs. ≤13%), whilst the "ASA ≥ 3" cohort failed to meet seven benchmarks.

Interpretation

These novel benchmark values can act as reference values to which sarcoma centers or individual surgeons can compare, which may help to identify performance gaps and improve the quality of care.

Funding

"5 x mille" fund for healthcare research (Italian Ministry of Health).

Diagnostic and predictive biomarkers of acute rejection after liver transplantation

Liver transplantation serves as a vital therapeutic intervention for individuals suffering from end-stage liver disease globally. A significant complication encountered by liver transplant recipients during the postoperative period is acute rejection, which has traditionally been identified through invasive graft biopsy procedures. Furthermore, assessing the immune status of liver transplant patients is essential for effective posttransplant management and represents a significant advancement toward the personalization of immunosuppressive therapy. Nevertheless, current immunological monitoring after the transplantation predominantly depends on clinical judgment and the measurement of immunosuppressive drug levels, lacking a comprehensive evaluation of actual immune system suppression. In contrast, biomarkers offer a comparatively novel and safer approach for the detection and prediction of transplant rejection, though their clinical application remains constrained due to the absence of prospective validation studies. This review examines the existing literature on potential biomarkers for acute rejection following liver transplantation, and their implications for clinical decision-making.

Impact of prognostic nutritional index on oncological outcomes and mortality among advanced gastric cancer patients: European GASTRODATA registry analysis

While Prognostic Nutritional Index (PNI) is an established predictor of outcomes in Asian gastric cancer (GC) patients, data among Western populations are limited. This study assessed the predictive value of PNI in European GC patients undergoing multimodal treatment. Data from GASTRODATA, the largest European repository of GC patients undergoing gastrectomy, were collected between 2017 and 2022. The primary outcome was textbook outcome (TO) achievement, and the secondary was 90-day mortality. PNI was calculated one day before surgery, with a cut-off of 45.5 based on ROC analysis. Among 721 patients included 60.7% were men. Most patients had advanced tumors (cT3-4 = 75.2%) and metastatic lymph nodes (57.7%). Neoadjuvant chemotherapy (NAC) was administered to 46.7% of patients, and 32.9% received adjuvant chemotherapy. Median PNI was 49.5 (IQR 45.0-56.4). Low PNI was present among 30% of patients and was associated with decreased odds of TO achievement (OR = 0.57, 95% CI 0.37-0.89), higher 90-day mortality (OR = 4.99, 95% CI 2.32-10.73). NAC administration was associated with lower morbidity risk (OR = 0.56, p = 0.0408), and low PNI was a predictor of receiving AC (p = 0.0005). PNI was a valuable predictor for oncological outcomes and morbidity among European GC patients undergoing multimodal. While low PNI was associated with decreased odds of TO achievement and increased risk of 90-day mortality, further prospective and nutritional intervention studies are warranted to standardize the PNI threshold and improve its clinical applicability.

Opportunities to improve mentorship of underrepresented minority nurse faculty on the tenure track: A Delphi study

BACKGROUND

Mentorship is essential for supporting doctorally prepared nurses transitioning into academic roles and for addressing the escalating nurse faculty shortage.

PURPOSE

The objective of this study was to gain consensus on barriers, facilitators, and metrics of successful mentorship of doctorally prepared underrepresented minority (URM) nurse faculty.

METHODS

A Delphi panel of doctorally prepared URM nurse faculty in the United States was convened. In Round 1, respondents answered open-ended questions identifying barriers, facilitators, and success metrics. In Round 2, participants rated their agreement using a 5-point scale. Round 3 included a focus group discussion.

DISCUSSION

The Round 1 survey was distributed to 107 URM nurse faculty, with 35 responses (32.7% response rate). Twenty-three of those participants completed Round 2 (65.7% retention). Top-ranked metrics included progress on milestones aligned with individual development plans and quality of mentor-mentee engagement.

CONCLUSION

This study underscores the importance of relational factors in effective mentorship.

Depth of Liver Invasion as a Novel Predictor for Outcome of Perihilar Cholangiocarcinoma

The current American Joint Committee on Cancer (AJCC) pT classification was inaccurate in predicting prognosis for perihilar cholangiocarcinoma (pCCA). This study aimed to propose a novel classification based on the depth of liver invasion (DOLI) of pCCA. Patients who underwent major hepatectomy combined with caudate lobectomy for pCCA between January 2015 and June 2023 were reviewed retrospectively. The maximum straight-line distance from the hepatic hilar plate to the infiltrated liver parenchyma was measured as DOLI. Log-rank statistics were used to determine the cutoff points. Among 167 patients, liver invasion was observed in 100 patients (59.9%). The cutoff points of DOLI for prognosis were 0 mm and 2.5 mm. DOLI was stratified into grade 1 (DOLI=0 mm; 67/167, 40.1%), grade 2 (0 mm2.5 mm; 37/167, 22.2%). The DOLI grade was associated with CA19-9 levels, tumor size, lymph node metastasis, perineural invasion, and portal vein invasion. The DOLI grade was an independent prognostic factor for both overall survival (OS) and recurrence-free survival (RFS) (both P<0.001), and demonstrated superior prognostic discrimination compared with the pT classification (C-indexes for OS and RFS: 0.67 vs. 0.63; 0.64 vs. 0.61). In conclusion, DOLI was an accurate prognostic indicator for pCCA. The 3-tier DOLI grades with cutoff points of 0 and 2.5 mm may serve as a potential alternative to the current pT classification.

Precision in Liver Surgery: A Comparative Analysis of Volumetry Techniques

BACKGROUND

Future liver remnant volume (FLRV) is a critical determinant of safety for hepatectomy. This study assesses concordance between imaging-based measured FLRV (mFLRV), and body surface area (BSA)-based standardized FLRV (sFLRV), and their association with post-hepatectomy complications.

MATERIALS AND METHODS

All major hepatectomy between 1999 and 2021 were assessed for agreement between mFLRV and sFLRV using concordance correlation coefficient (CCC). Association between each method and major postoperative complications, post-hepatectomy liver failure (PHLF), or grade 4/5 morbidity was compared using logistic regression model and area under the receiver-operating characteristic (AUC) curve to evaluate the discriminatory power of each volumetry method separately.

RESULTS

A total of 1749 patients were included, 49% were female, median age was 60 years, 70.2% had metastatic disease, and 49.7% received preoperative chemotherapy. Median sFLRV (41.3%) was higher than mFLRV (39.4%). Major complications were observed in 5.1% (n = 90). Concordance between mFLRV and sFLRV was moderate, CCC = 0.78 (95% CI 0.75-0.79) but was poor (CCC = 0.39; 95% CI 0.32-0.43) among patients with mFLRV ≤ 35% (n = 528). In this subset, sFLRV overestimated remnant volume in 63% (n = 333) with ≥ 5% overprediction in 145 patients (27.5%). Factors associated with ≥ 5% variation were lower weight (p = 0.003), lower BMI (p = 0.003), and lower BSA (p = 0.004). Both methods performed similarly in predicting major complications with AUC of 0.64 and 0.63 for sFLRV and mFLRV, respectively.

CONCLUSIONS

Imaging- and BSA-based volumetry are moderately correlated, with poor concordance among patients with smaller FLRV where sFLRV overestimated remnant volume. Both techniques can be safely used for volumetric assessment before major hepatectomy.

Hepatopancreatoduodenectomy for Extrahepatic Cholangiocarcinoma: A Series of 100 Consecutive Cases from an Expert Center in Japan

OBJECTIVE

This study was designed to evaluate the efficacy and safety of hepatopancreatoduodenectomy (HPD) for extrahepatic cholangiocarcinoma, because it remains controversial owing to high morbidity and mortality, as well as uncertain oncological benefits.

METHODS

Patients who underwent HPD between 2003 and 2020 were reviewed. Short- and long-term outcomes were compared with those of patients who underwent hepatectomy with extrahepatic bile duct resection (HT-B) and pancreatoduodenectomy (PD) for extrahepatic cholangiocarcinoma.

RESULTS

In the study interval, 100 patients underwent HPD, 203 underwent HT-B and 209 underwent PD. The median operating time and blood loss of HPD were 668 min and 1,842 mL, which were significantly longer and greater in comparison to the HT-B (552 min and 1,264 ml) and PD (457 min and 911 ml) groups. The rate of clinically relevant postoperative complications (Clavien-Dindo grade ≥ 3) after HPD was 82%, which was significantly greater in comparison to the HT-B (39%) and PD (68%) groups. However, the mortality rate was 2% and was almost comparable to the HT-B (2.5%) and PD (1.4%) groups. The 3- and 5-year survival rates and median survival times were 59%, 40.7%, and 50 months, respectively, in the HPD group; 61.1%, 41.8%, and 45 months in the HT-B group; and 60.7%, 45.4%, and 48 months in the PD group. No significant differences were observed between the groups.

CONCLUSIONS

Although HPD is technically demanding and forces stress on patients, it can be performed with acceptable mortality and survival rate, and is an acceptable option for patients cared for in expert hepatopancreatobiliary centers.

Single-Incision Laparoscopy in Abdominal Trauma: Current Evidence, Clinical Applications, and Evolving Role-A Narrative Review

Background/Objectives: Laparoscopic surgery plays a central role in the management of abdominal trauma, particularly in patients with hemodynamic stability. Recently, single-port laparoscopic surgery (SPLS) has emerged as a technique that further reduces access-related trauma while preserving the benefits of conventional laparoscopy. Thus, this review aimed to examine the current landscape of SPLS in trauma care, summarizing available clinical data and highlighting practical considerations for its use. Despite the limited experience, early evidence suggests that SPLS can achieve diagnostic and therapeutic outcomes comparable to those achieved by multi-port approaches in selected cases. Particular attention is given to a hybrid method that combines intracorporeal assessment with extracorporeal small bowel examination and repair through a single umbilical incision. This technique offers a pragmatic balance between thorough exploration and minimal invasiveness. Methods: We searched PubMed, Scopus, Web of Science, and Google Scholar through December 2023 using the terms "single-port laparoscopy", "single-incision laparoscopic surgery", "trauma laparoscopy", and related phrases. Case reports, case series, comparative studies, and reviews describing single-incision laparoscopic surgery in trauma were included in this narrative analysis. Results: SPLS may offer advantages in terms of postoperative pain, wound complications, and cosmetic outcomes, especially in younger patients. As familiarity with the approach increases and dedicated instrumentation becomes more accessible, its role in trauma protocols may expand. Conclusions: Further prospective research is needed to define long-term outcomes, refine patient selection, and integrate SPLS more systematically into trauma care protocols.

The role of veno-venous bypass in liver transplant

PURPOSE OF REVIEW

Veno-venous bypass (VVB) ensures end-organ perfusion and minimizes splanchnic venous congestion during liver transplant procedures. The adoption of the piggyback technique, where flow through the inferior vena cava is preserved, has prompted a decline in the routine use of VVB. Meanwhile, recommendations on VVB use in liver transplantation remain equivocal. This article explores the clinical implications of VVB use in liver transplantation and offers a comprehensive analysis of its benefits and risks in the context of recent surgical advancements.

RECENT FINDINGS

Evidence indicates that patients undergoing complex procedures or with baseline renal dysfunction may benefit from VVB for conventional liver resection, emphasizing the need for careful patient selection. By contrast, small, retrospective studies suggest lower transfusion requirements and improved graft survival when the piggyback approach was used without VVB, but evidence remains sparse. While direct bypass cannulation-associated complications remain a concern, technical advancements have made VVB use increasingly safe.

SUMMARY

In conclusion, VVB remains an important tool in selected, high-acuity patients, but offers limited benefit in more stable patients undergoing piggyback liver resection. Large-scale randomized studies are needed to elucidate the benefit of VVB in selected patient populations undergoing procedures with different surgical approaches.

Laparoscopic associating liver partition and portal vein ligation for staged hepatectomy for colorectal liver metastases: A single-center experience

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a procedure used for patients with initially unresectable colorectal liver metastases (CRLM). However, the procedure has been reported to be associated with high morbidity and mortality. Laparoscopic ALPPS has recently been reported as a minimally invasive technique that reduces perioperative risks.

AIM

To assess the safety and feasibility of full laparoscopic ALPPS in patients with CRLM.

METHODS

A retrospective analysis was conducted on all consecutive patients with CRLM who underwent full laparoscopic ALPPS at the Sixth Affiliated Hospital of Sun Yat-sen University between March 2021 and July 2024.

RESULTS

Fifteen patients were included, 13 with synchronous liver metastases. Nine patients had more than five liver tumors, with the highest count being 22. The median diameter of the largest lesion was 2.8 cm on preoperative imaging. No extrahepatic metastases were observed. RAS mutations were detected in nine patients, and 14 underwent preoperative chemotherapy. The median increase in future liver remnant volume during the interstage interval was 47.0%. All patients underwent R0 resection. Overall complication rates were 13.3% (stage 1) and 53.3% (stage 2), while major complication rates (Clavien-Dindo ≥ IIIa) were 13.3% (stage 1) and 33.3% (stage 2). No mortality occurred in either stage. The median hospital stay after stage 2 was 10 days.

CONCLUSION

Full laparoscopic ALPPS for CRLM is safe and feasible, with the potential for reduced morbidity and mortality, offering radical resection opportunities for patients with initially unresectable CRLM.

The Role of Ancient Greek Physicians in the Development of Tracheostomy: Pioneering Airway Interventions and Early Thoracic Surgery

Tracheostomy, a critical airway intervention, has a long and complex history that dates back to antiquity. While the earliest references to the procedure appear in Egyptian and Indian medical texts, its development within ancient Greek medicine remains a subject of historical debate. This study explores the evolution of tracheostomy in ancient Greece, analyzing its theoretical foundations, historical accounts, and surgical advancements. Despite Hippocratic opposition, which largely discouraged invasive airway procedures due to the risk of fatal complications, later physicians such as Asclepiades, Aretaeus, and Antyllus made significant contributions to refining airway management techniques. The anatomical studies of Galen further advanced the understanding of respiratory physiology, including early concepts of artificial ventilation. Additionally, this study examines archaeological evidence, such as a marble relief discovered in Abdera, which may depict an early attempt at tracheostomy, providing valuable insight into the practical application of airway interventions in antiquity. By comparing ancient Greek surgical techniques with modern tracheostomy practices, this research highlights the continuity of medical knowledge and innovation. It underlines the role of ancient Greek physicians in shaping the principles of thoracic surgery, offering a broader understanding of how early medical practices have influenced contemporary airway management. The findings contribute to the historical perspective on tracheostomy, emphasizing the timeless pursuit of life-saving surgical advancements and the evolving relationship between theoretical medical knowledge and practical surgical application.

European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu, European Association for the Study of the Liver. EASL Clinical Practice Guidelines on extrahepatic abdominal surgery in patients with cirrhosis and advanced chronic liver disease

Extrahepatic abdominal surgery in patients with cirrhosis of the liver represents a growing clinical challenge due to the increasing prevalence of chronic liver disease and improved long-term survival of these patients. The presence of cirrhosis significantly increases the risk of perioperative morbidity and mortality following abdominal surgery. Advances in preoperative risk stratification, surgical techniques, and perioperative care have led to better outcomes, yet integration of these improvements into routine clinical practice is needed. These clinical practice guidelines provide comprehensive recommendations for the assessment and perioperative management of patients with cirrhosis undergoing extrahepatic abdominal surgery. An individualised patient-centred risk assessment by a multidisciplinary team including hepatologists, surgeons, anaesthesiologists, and other support teams is essential.

Liver transplantation as a treatment for cancer: comprehensive review

BACKGROUND

Liver transplantation for cancer indications has gained momentum in recent years. This review is intended to optimize the care setting of liver transplant candidates by highlighting current indications, technical aspects and barriers with available solutions to facilitate the guidance of available strategies for healthcare professionals in specialized centres.

METHODS

A review of the most recent relevant literature was conducted for all the cancer indications of liver transplantation including colorectal cancer liver metastases, hilar cholangiocarcinoma, intrahepatic cholangiocarcinoma, neuroendocrine tumours, hepatocellular carcinoma and hepatic epitheloid haemangioendothelioma.

RESULTS

Transplant benefit from the best available evidence, including SECA I, SECA II, TRANSMET studies for colorectal liver metastases, various preoperative protocols for cholangiocarcinoma patients, standard, extended selection criteria for hepatocellular carcinoma and neuroendocrine tumours, are discussed. Innovative approaches to deal with organ shortages, including machine-perfused deceased grafts, living donor liver transplantation and RAPID procedures, are also explored.

CONCLUSION

Cancer indications for liver transplantation are here to stay, and the selection criteria among all cancer groups are likely to evolve further with improved prognostication of tumour biology using adjuncts such as radiomics, cancer genomics, and circulating DNA and RNA status. International prospective registry-based studies could overcome the limitations of smaller patient cohorts and lack of level 1 evidence.

Navigating Complexity in Liver Resection: A Narrative Review of Factors Influencing Intraoperative Difficulty

Background: Liver resection remains the cornerstone for curative management in primary liver malignancies. Liver surgery ranges from simple wedge resections to complex hepatectomies involving vascular or biliary reconstructions. The anatomical complexity of the liver and these varied surgical approaches create challenges in assessing operative difficulty. This literature review explores the key factors influencing operative difficulty in liver resection for primary liver malignancy across surgical techniques. Methods: A broad literature review was conducted to determine the factors that were associated with increased operative difficulty in liver resection using the Embase, PubMed, and Cochrane databases for studies published between 2000 and 2025. Results: This review identifies several patient, tumor, and surgical factors that influence operative difficulty in liver resection. Numerous difficult scoring systems were identified, yet their applicability across different operative approaches remains uncertain. Across open and minimally invasive techniques, tumor size and location are commonly used to determine complexity. However, debate remains regarding the optimal cutoff for tumor diameter. Other identified factors include the extent of resection, patient-specific variables (e.g., cirrhosis, body mass index, previous surgeries), and surgical technique. In addition, liver resection procedures classified based on the 2000 Brisbane terminology have been stratified into three groups of increasing difficulty. Conclusion: The ability to predict operative difficulty is useful for case selection, surgical planning, and risk stratification for meaningful shared decision-making. Future research should focus on refining predictive models by integrating composite measures, including patient-reported outcomes and long-term survival. A unified, validated scoring system applicable across surgical techniques could enhance consistency in clinical practice and research to improve outcomes.

Effect of Preoperative Autologous Blood Storage in Major Hepatectomy for Perihilar Malignancy: A Randomized Controlled Trial

OBJECTIVE

To reappraise whether preoperative autologous blood donation reduces post-hepatectomy liver failure (PHLF) in major hepatectomy for perihilar malignancy.

SUMMARY BACKGROUND DATA

Autologous blood storage and transfusion are carried out to reduce the use of allogeneic blood transfusion during hepatectomy and prevent postoperative complications. However, the clinical benefit of major hepatectomy has been controversial.

METHODS

This randomized clinical trial included patients who underwent major hepatectomy with extrahepatic bile duct resection for perihilar malignancy. Eligible patients were randomly assigned (1:1) to undergo surgery with or without the use of autologous blood transfusion. The primary outcome was the incidence of clinically relevant PHLF (grade B/C according to the International Study Group of Liver Surgery definition).

RESULTS

Between February 6, 2019, and May 12, 2023, 138 consecutive patients were enrolled in the study (blood storage group n=68, non-storage group n=70). Twenty-five patients who did not undergo resection were excluded; the remaining 113 patients were investigated as the full analysis set (blood storage group n=60, non-storage group n=53). Surgical procedures, operative time, and blood loss were not significantly different between the 2 groups. The incidence of PHLF was comparable [blood storage group n=10 (17%), non-storage group n=10 (19%); P =0.760]. There were also no between-group differences in other postoperative outcomes, including the incidence of Clavien-Dindo Grade Ⅲ or higher (72% vs 72%, P =0.997) and median duration of hospital stay (25 vs 29 days, P =0.277).

CONCLUSIONS

Autologous blood storage did not contribute to reducing the incidence of PHLF in patients undergoing major hepatectomy.

The Critical Role of Regulatory T Cells in Immune Tolerance and Rejection Following Liver Transplantation: Interactions With the Gut Microbiome

Liver transplantation (LT) is the ultimate treatment for patients with end-stage liver disease or early hepatocellular carcinoma. In the context of LT, because of the unique immunological characteristics of human liver allograft, 5%-20% of selected LT recipients can achieve operational tolerance. Nonetheless, there remains a risk of rejection in LT patients. Maintaining immune homeostasis is thus crucial for improving clinical outcomes in these patients. In mechanism, several immune cells, including dendritic cells, Kupffer cells, myeloid-derived suppressor cells, hepatic stellate cells, regulatory B cells, and CD4 + regulatory T cells (Treg), contribute to achieving tolerance following LT. In terms of Treg, it plays a role in successfully minimizing immunosuppression or achieving tolerance post-LT while also reducing the risk of rejection. Furthermore, the gut microbiome modulates systemic immune functions along the gut-liver axis. Recent studies have explored changes in the microbiome and its metabolites under various conditions, including post-LT, acute rejection, and tolerance. Certain functional microbiomes and metabolites exhibit immunomodulatory functions, such as the augmentation of Treg, influencing immune homeostasis. Therefore, understanding the mechanisms of tolerance in LT, the role of Treg in tolerance and rejection, as well as their interactions with gut microbiome, is vital for the management of LT patients.

Clinical and financial impact of a 'difficult' laparoscopic cholecystectomy

BACKGROUND

Difficult intra-operative findings during laparoscopic cholecystectomy (LC) may lead to poor clinical outcomes. This study aimed to compare pre-operative, intra-operative, and post-operative variables of patients with 'straightforward' versus 'difficult' intra-operative findings and to assess the relationship between intra-operative findings and post-operative outcomes.

METHODS

A retrospective cohort study of prospectively collected data from patients undergoing LC from August 1998 to December 2020 was conducted. Intra-operative findings were graded using the North Shore system, with Grade 1 or 2 classified as 'straightforward' LC and Grade 3 or 4 as 'difficult' LC. Logistic regression analyzed the relationship between poor post-operative outcomes and intra-operative findings.

RESULTS

Among 2633 patients, 2050 (78%) had 'straightforward' and 583 (22%) had 'difficult' intra-operative findings. Patients with 'difficult' findings were often younger, male, jaundiced, had higher Charlson Comorbidity Indexes (CCI), and were more likely to undergo urgent or semi-urgent operations in the public hospital. They experienced longer operation times, higher cholangiogram failure rates, more common bile duct explorations, longer hospital stays, higher conversion rates to open procedures, a greater risk of post-operative bile leaks, and higher rates of hospital readmission post-discharge. Higher CCI, pancreatitis, and intra-operative challenges such as CBD exploration and 'difficult' intra-operative findings were predictive of poor post-operative outcomes. The financial impact of 'difficult' intra-operative findings is significant.

CONCLUSION

There is an association between 'difficult' intra-operative findings and adverse clinical outcomes, confirming the negative financial impact of a less-than Textbook Outcome. This highlights the need to anticipate and make appropriate resources available for potentially challenging LCs.

Comprehensive Survival Analysis of Alveolar Echinococcosis Patients, University Hospital Zurich, Zurich, Switzerland, 1973-2022

Alveolar echinococcosis (AE) is a zoonotic disease of increasing concern worldwide. Before benzimidazole drug therapy, 10-year death rates were 90% without surgical resection. In unresectable patients, long-term benzimidazole therapy is highly effective in stabilizing the disease course. We performed a retrospective study of 334 AE patients treated at the University Hospital Zurich, Zurich, Switzerland, during 1973-2022. Annual diagnoses increased over time, and more cases were detected by chance at earlier stages. Ninety patients died, mostly from causes unrelated to AE. Relative survival of AE patients compared with the population of Switzerland demonstrated a steady decrease 5 years after diagnosis. Patient age at diagnosis was the primary variable associated with overall survival. In a propensity-score matched survival analysis, early curative surgery was associated with overall improvement but not AE-specific survival. We conclude that survival of patients with AE is limited by non-AE causes and that early curative surgery does not improve AE-specific survival.

Satisfaction evaluation of interns with Da Vinci robot surgical demonstration training in gynecologic oncology operations

Objective

This study aimed to assess the satisfaction levels of medical interns undergoing training in Da Vinci robot-assisted surgery at the Women's Hospital.

Design

Between Aug 2023 and Mar 2024, an intern surgical demonstration training was conducted with students in medicine in the Department of Gynecologic Oncology. While the doctor operated from the primary console, a student utilized the 3D perspective from the second console to closely follow the lead surgeon's surgical maneuvers in real-time. After completing the training, the students filled out a questionnaire to assess their satisfaction with the proposed training.

Results

Through structured questionnaires and interviews, 18 interns' perceptions and suggestions regarding the training program were evaluated. All students supported the Da Vinci surgical teaching model over traditional teaching methods. The findings revealed the interns' overall satisfaction with an average five-point Likert scale score of 4.88. Students' responses highly evaluated the usefulness of Da Vinci surgical training in improving surgical practice capabilities with an average five-point Likert scale score of 4.78. 94% of the students looked forward to using the da Vinci surgical system in future surgeries, and 83% of the participants would continue their further education and training in the field of robotic surgery. Using a 10-point scoring system to evaluate students' mastery of surgical knowledge gained from this training, the average score obtained was 8.94. Notably, follow-up data revealed that 12 out of these 18 students eventually chose surgery as their specialization when selecting their master's degree direction.

Conclusion

Training in robot-assisted surgery demonstration of gynecologic oncology operations is a useful approach for training students to master surgical anatomy and develop skills in the field of surgery.

Expanding the Liver Donor Pool: Promise and Peril

Liver transplantation remains a life-saving therapy for a growing list of indications. Although 10,660 adult liver transplants were performed in the United States in 2023, a 50% increase over the preceding decade, the demand continues to far exceed the supply. Efforts to expand the liver donor pool by using donors that were previously considered unsuitable have remained an important strategy to help overcome shortages. We discuss the progress that has been made over the past decade, as well as potential future barriers that will need to be overcome to help successfully expand the liver donor pool.

Annual report of Japanese biliary tract cancer registry from 2021: Focus on the rate of R0 resection, postoperative complications, and site of lymph node metastasis

PURPOSE

This study aimed to clarify the current treatment status for biliary tract cancers based on data from the National Clinical Database (NCD) in Japan.

METHODS

Total 3895 cases of biliary tract cancers registered in the NCD during 2021 were included. We identified the rates of resection, R0 resection, postoperative complications, and incidences of lymph node metastasis for gallbladder carcinoma, perihilar cholangiocarcinoma, distal bile duct carcinoma, and ampullary carcinoma.

RESULTS

The number of biliary tract cancers registered in the NCD during 2021 was 3895 (1775 in extrahepatic bile duct carcinoma, 1422 in gallbladder carcinoma, and 698 in ampullary carcinoma). In gallbladder carcinoma, the resection (89.59%) and R0 resection rates (87.99%) were favorable, and the complication rate (6.05%) was lower than that of others. However, the postoperative complication rate could be higher in T3-T4 cases and when extrahepatic bile duct resection was performed concomitantly. Lymph node metastasis was frequently seen in 12.60% at the No. 13a lymph node. In perihilar cholangiocarcinoma, the R0 resection (69.82%) and complication rates (16.75%) were significantly lower and higher, respectively. In distal cholangiocarcinoma and ampullary carcinoma, metastasis was observed in approximately 2% and 10% of the dissected No. 16b1 para-aortic lymph nodes, respectively. In conclusion, although short-term surgical outcomes for biliary tract cancers in Japan might be acceptable, the significantly lower R0 resection and higher complication rates of perihilar cholangiocarcinomas indicate additional challenges for surgeons in the future and should continue to be monitored by the Japanese Society of Hepatobiliary and Pancreatic Surgery.

Central hepatectomy for perihilar cholangiocarcinoma: an alternative technique for parenchymal-sparing hepatectomy to prevent post-hepatectomy liver failure

BACKGROUND

Perihilar cholangiocarcinoma (PHC) often requires major hepatectomy with extrahepatic bile duct resection, carrying the risk of post-hepatectomy liver failure (PHLF). Central hepatectomy (CH), an alternative technique, aims to preserve functional liver reserve. This study evaluated the feasibility of CH and outcomes for patients with PHC within the paradigm of parenchymal-sparing hepatectomy.

METHODS

A retrospective analysis included PHC patients who underwent CH between March 2019 and January 2023. Preoperative evaluations involved multimodality imaging and assessment of future remnant liver volume.

RESULTS

Fourteen patients underwent CH for PHC. Tumor locations were perihilar bile duct (10 patients), and entire extrahepatic bile duct involvement (four patients). Median operative time and intraoperative blood loss were 679.5 min and 450 mL, respectively. Clinically-relevant PHLF occurred in two patients, with one sepsis-related death. Nine patients achieved R0 resection. Functional liver reserve parameters exceeded the standard procedure (p < 0.01).

CONCLUSION

CH for PHC preserves functional liver reserve, potentially reducing PHLF risk. Adequate preoperative evaluation is crucial, and oncological outcomes require further investigation.

Immunosuppression Post-Liver Transplant: End of the Calcineurin Era?

The introduction of calcineurin inhibitors (CNIs) as the primary form of immunosuppression (IS) for liver transplantation (LT) in the late 1970s was a key in increasingly successful outcomes for transplantation over the past 3 decades. Despite the side effects of CNI which directly contribute to the long-term morbidity and mortality post-LT, they will remain the cornerstone of IS in the near future. Efforts to minimize exposure to CNI will require the application of blood and tissue biomarkers that accurately identify the extent of IS and risk of rejection for individual patients.

Extreme surgery using the hypothermic perfusion technique for conventionally unresectable abdominal malignant tumours: A systematic review and meta-analysis

BACKGROUND

Extreme surgery using the hypothermic perfusion technique is often the only treatment option to achieve R0 resection and long-term prognosis for abdominal tumours that are either conventionally unresectable or contraindicated to allotransplantation. We conducted a systematic review and meta-analysis to delineate the indications and outcomes of extreme surgery.

MATERIALS AND METHODS

Human studies on extreme resection for abdominal malignant tumours were searched among five databases between January 1988 to March 2023. The Risk Of Bias In Non-randomised Studies - of Interventions tool was used to assess the risk of bias. A meta-analysis of proportions was performed, pooling 1-, 3- and 5-year overall survival and recurrence rates.

RESULTS

This study comprised 73 studies encompassing 333 patients who underwent extreme liver resection (in situ, n = 127; ante situm, n = 72; ex situ, n = 134). Additionally, 90 patients from 17 studies focusing on extreme resection of other (non-hepatic) organs were included. The pooled 90-day mortality and 1- and 5-year overall survival rates were 7.3 %, 72.3 % and 23.4 %, respectively. The 1- and 5-year recurrence rates were 38.7 % and 86.1 %, respectively. Patients aged <65 years had a significantly lower 90-day mortality (5.5 % vs. 29.6 %; P = 0.022) and a higher 5-year overall survival rate (23.9 % vs. 0 %; P < 0.001) than those aged ≥65 years. Additionally, non-epithelial tumours were associated with favourable prognosis compared with epithelial tumours.

CONCLUSION

Extreme surgery offers acceptable outcomes for younger patients with non-epithelial tumours that are either unresectable by conventional cancer surgery or contraindicated to allotransplantation.

EASL Clinical Practice Guidelines on the management of extrahepatic cholangiocarcinoma

Recent years have witnessed significant advances in the imaging, molecular profiling, and systemic treatment of cholangiocarcinoma (CCA). Despite this progress, the early detection, precise classification, and effective management of CCA remain challenging. Owing to recent developments and the significant differences in CCA subtypes, EASL commissioned a panel of experts to draft evidence-based recommendations on the management of extrahepatic CCA, comprising distal and perihilar CCA. Particular attention is given to the need for accurate classification systems, the integration of emerging molecular insights, and practical strategies for diagnosis and treatment that reflect real-world clinical scenarios.

Hepatocellular Carcinoma and the Role of Liver Transplantation: An Update and Review

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related death worldwide. Multiple treatment modalities are available for the management of HCC, depending on its stage as determined by the Barcelona Clinic Liver Cancer staging system. Because liver transplantation (LT) theoretically removes the cancer and replaces the organ at risk for future malignancy, LT is often considered the most definitive and one of the most efficacious treatment options for HCC. Nevertheless, the success and efficacy of liver transplantation depend on various tumor characteristics. As a result, multiple criteria have been developed to assess the appropriateness of a case of HCC for LT, with the pioneering Milan Criteria established in 1996. Over the past 20 to 30 years, these criteria have been critically evaluated, expanded, and often liberalized to make LT for patients with HCC a more universally applicable option. Furthermore, the development of other treatment modalities has enabled downstaging and bridging strategies for HCC prior to LT. In this narrative and comprehensive review, we provided an update on recent trends in the epidemiology of HCC, selection criteria for LT, implementation of LT across different regions, treatment modalities available as bridges, downstaging strategies, alternatives to LT, and, finally, post-LT surveillance.