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Introduction: Despite the increasing widespread adoption and experience in minimally invasive liver resections (MILR), open conversion occurs not uncommonly even with minor resections and as been reported to be associated with inferior outcomes. We aimed to identify risk factors for and outcomes of open conversion in patients undergoing minor hepatectomies. We also studied the impact of approach (laparoscopic or robotic) on outcomes., Methods: This is a post-hoc analysis of 20,019 patients who underwent RLR and LLR across 50 international centers between 2004-2020. Risk factors for and perioperative outcomes of open conversion were analysed. Multivariate and propensity score-matched analysis were performed to control for confounding factors., Results: Finally, 10,541 patients undergoing either laparoscopic (LLR; 89.1%) or robotic (RLR; 10.9%) minor liver resections (wedge resections, segmentectomies) were included. Multivariate analysis identified LLR, earlier period of MILR, malignant pathology, cirrhosis, portal hypertension, previous abdominal surgery, larger tumor size, and posterosuperior location as significant independent predictors of open conversion. The most common reason for conversion was technical issues (44.7%), followed by bleeding (27.2%), and oncological reasons (22.3%). After propensity score matching (PSM) of baseline characteristics, patients requiring open conversion had poorer outcomes compared with successful MILR cases as evidenced by longer operative times, more blood loss, higher requirement for perioperative transfusion, longer duration of hospitalization and higher morbidity, reoperation, and 90-day mortality rates., Conclusions: Multiple risk factors were associated with conversion of MILR even for minor hepatectomies, and open conversion was associated with significantly poorer perioperative outcomes., (© 2024. Society of Surgical Oncology.)

Background: Minimally invasive liver resections (MILR) offer potential benefits such as reduced blood loss and morbidity compared with open liver resections. Several studies have suggested that the impact of cirrhosis differs according to the extent and complexity of resection. Our aim was to investigate the impact of cirrhosis on the difficulty and outcomes of MILR, focusing on major hepatectomies., Methods: A total of 2534 patients undergoing minimally invasive major hepatectomies (MIMH) for primary malignancies across 58 centers worldwide were retrospectively reviewed. Propensity score (PSM) and coarsened exact matching (CEM) were used to compare patients with and without cirrhosis., Results: A total of 1353 patients (53%) had no cirrhosis, 1065 (42%) had Child-Pugh A and 116 (4%) had Child-Pugh B cirrhosis. Matched comparison between non-cirrhotics vs Child-Pugh A cirrhosis demonstrated comparable blood loss. However, after PSM, postoperative morbidity and length of hospitalization was significantly greater in Child-Pugh A cirrhosis, but these were not statistically significant with CEM. Comparison between Child-Pugh A and Child-Pugh B cirrhosis demonstrated the latter had significantly higher transfusion rates and longer hospitalization after PSM, but not after CEM. Comparison of patients with cirrhosis of all grades with and without portal hypertension demonstrated no significant difference in all major perioperative outcomes after PSM and CEM., Conclusions: The presence and severity of cirrhosis affected the difficulty and impacted the outcomes of MIMH, resulting in higher blood transfusion rates, increased postoperative morbidity, and longer hospitalization in patients with more advanced cirrhosis. As such, future difficulty scoring systems for MIMH should incorporate liver cirrhosis and its severity as variables., (© 2023. Society of Surgical Oncology.)

Introduction: Although tumor size (TS) is known to affect surgical outcomes in laparoscopic liver resection (LLR), its impact on laparoscopic major hepatectomy (L-MH) is not well studied. The objectives of this study were to investigate the impact of TS on the perioperative outcomes of L-MH and to elucidate the optimal TS cutoff for stratifying the difficulty of L-MH., Methods: This was a post-hoc analysis of 3008 patients who underwent L-MH at 48 international centers. A total 1396 patients met study criteria and were included. The impact of TS cutoffs was investigated by stratifying TS at each 10-mm interval. The optimal cutoffs were determined taking into consideration the number of endpoints which showed a statistically significant split around the cut-points of interest and the magnitude of relative risk after correction for multiple risk factors., Results: We identified 2 optimal TS cutoffs, 50 mm and 100 mm, which segregated L-MH into 3 groups. An increasing TS across these 3 groups (≤ 50 mm, 51-100 mm, > 100 mm), was significantly associated with a higher open conversion rate (11.2%, 14.7%, 23.0%, P < 0.001), longer operating time (median, 340 min, 346 min, 365 min, P = 0.025), increased blood loss (median, 300 ml,  ml, 400 ml, P = 0.002) and higher rate of intraoperative blood transfusion (13.1%, 15.9%, 27.6%, P < 0.001). Postoperative outcomes such as overall morbidity, major morbidity, and length of stay were comparable across the three groups., Conclusion: Increasing TS was associated with poorer intraoperative but not postoperative outcomes after L-MH. We determined 2 TS cutoffs (50 mm and 10 mm) which could optimally stratify the surgical difficulty of L-MH., (© 2023. Society of Surgical Oncology.)

Introduction: Despite the advances in minimally invasive (MI) liver surgery, most major hepatectomies (MHs) continue to be performed by open surgery. This study aimed to evaluate the risk factors and outcomes of open conversion during MI MH, including the impact of the type of approach (laparoscopic vs. robotic) on the occurrence and outcomes of conversions., Methods: Data on 3880 MI conventional and technical (right anterior and posterior sectionectomies) MHs were retrospectively collected. Risk factors and perioperative outcomes of open conversion were analyzed. Multivariate analysis, propensity score matching, and inverse probability treatment weighting analysis were performed to control for confounding factors., Results: Overall, 3211 laparoscopic MHs (LMHs) and 669 robotic MHs (RMHs) were included, of which 399 (10.28%) had an open conversion. Multivariate analyses demonstrated that male sex, laparoscopic approach, cirrhosis, previous abdominal surgery, concomitant other surgery, American Society of Anesthesiologists (ASA) score 3/4, larger tumor size, conventional MH, and Institut Mutualiste Montsouris classification III procedures were associated with an increased risk of conversion. After matching, patients requiring open conversion had poorer outcomes compared with non-converted cases, as evidenced by the increased operation time, blood transfusion rate, blood loss, hospital stay, postoperative morbidity/major morbidity and 30/90-day mortality. Although RMH showed a decreased risk of conversion compared with LMH, converted RMH showed increased blood loss, blood transfusion rate, postoperative major morbidity and 30/90-day mortality compared with converted LMH., Conclusions: Multiple risk factors are associated with conversion. Converted cases, especially those due to intraoperative bleeding, have unfavorable outcomes. Robotic assistance seemed to increase the feasibility of the MI approach, but converted robotic procedures showed inferior outcomes compared with converted laparoscopic procedures., (© 2023. Society of Surgical Oncology.)

Introduction: The Iwate Score (IS) have not been well-validated for specific procedures, especially for right posterior sectionectomy (RPS). In this study, the utility of the IS was determined for laparoscopic (L)RPS and the effect of tumor location on surgical outcomes was investigated., Methods: Post-hoc analysis of 647 L-RPS performed in 40 international centers of which 596L-RPS cases met the inclusion criteria. Baseline characteristics and perioperative outcomes of patients stratified based on the Iwate score were compared to determine whether a correlation with surgical difficulty existed. A 1:1 Mahalanobis distance matching was utilized to investigate the effect of tumor location on L-RPS outcomes., Results: The patients were stratified into 3 levels of difficulty (31 intermediate, 143 advanced, and 422 expert) based on the IS. When using a stepwise increase of the IS excluding the tumor location score, only Pringle's maneuver was more frequently used in the higher surgical difficulty level (35.5%, 54.6%, and 65.2%, intermediate, advanced, and expert levels, respectively, Z = 3.34, p = 0.001). Other perioperative results were not associated with a statistical gradation toward higher difficulty level. 80 of 85 patients with a segment VI lesion and 511 patients with a segment VII lesion were matched 1:1. There were no significant differences in the perioperative outcomes of the two groups including open conversion, operating time, blood loss, intraoperative blood transfusion, postoperative stay, major morbidity, and mortality., Conclusion: Among patients undergoing L-RPS, the IS did not significantly correlate with most outcome measures associated with intraoperative difficulty and postoperative outcomes. Similarly, tumor location had no effect on L-RPS outcomes., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Although laparoscopic liver resection has become the standard for minor resections, evidence is lacking for more complex resections such as the right posterior sectionectomy (RPS). We aimed to compare surgical outcomes between laparoscopic (LRPS) and open right posterior sectionectomy (ORPS)., Methods: An international multicenter retrospective study comparing patients undergoing LRPS or ORPS (January 2007-December 2018) was performed. Patients were matched based on propensity scores in a 1:1 ratio. Primary endpoint was major complication rate defined as Accordion ≥ 3 grade. Secondary endpoints included blood loss, length of hospital stay (LOS) and resection status. A sensitivity analysis was done excluding the first 10 LRPS patients of each center to correct for the learning curve. Additionally, possible risk factors were explored for operative time, blood loss and LOS., Results: Overall, 399 patients were included from 9 centers from 6 European countries of which 150 LRPS could be matched to 150 ORPS. LRPS was associated with a shorter operative time [235 (195-285) vs. 247 min (195-315) p = 0.004], less blood loss [260 (188-400) vs. 400 mL (280-550) p = 0.009] and a shorter LOS [5 (4-7) vs. 8 days (6-10), p = 0.002]. Major complication rate [n = 8 (5.3%) vs. n = 9 (6.0%) p = 1.00] and R0 resection rate [144 (96.0%) vs. 141 (94.0%), p = 0.607] did not differ between LRPS and ORPS, respectively. The sensitivity analysis showed similar findings in the previous mentioned outcomes. In multivariable regression analysis blood loss was significantly associated with the open approach, higher ASA classification and malignancy as diagnosis. For LOS this was the open approach and a malignancy., Conclusion: This international multicenter propensity score-matched study showed an advantage in favor of LRPS in selected patients as compared to ORPS in terms of operative time, blood loss and LOS without differences in major complications and R0 resection rate., (© 2020. The Author(s).)

Background: This study aimed to externally validate the Iwate scoring model and its prognostic value for predicting the risks of intra- and postoperative complications of laparoscopic liver resection., Methods: Consecutive patients who underwent pure laparoscopic liver resection between 2008 and 2019 at a single tertiary center were included. The Iwate scores were calculated according to the original proposition (four difficulty levels based on six indices). Intra- and postoperative complications were compared across difficulty levels. Fitting the obtained data to the cumulative density function of the Weibull distribution and a linear function provided the mean risk curves for intra- and postoperative complications, respectively., Results: The difficulty levels of 142 laparoscopic liver resections were scored as low, intermediate, advanced, and expert level in 41 (28.9%), 53 (37.3%), 32 (22.5%), and 16 (11.3%) patients, respectively. Intraoperative complications were detected in 26 (18.3%) patients and its rates (2.4%, 7.5%, 34.3%, and 62.5%) increased gradually with statistically significant values among difficulty levels (P ˂ 0.001). Major postoperative complications occurred in 21 (14.8%) patients and its rates (4.8%, 5.6%, 28.1%, 43.7%; P ˂ 0.001) showed the same trend as for intraoperative complications. Then, the mean risk curves of both complications were obtained. Due to outliers, a new threshold for a tumor size index was proposed at 38 mm. The repeated analysis showed improved results., Conclusions: The Iwate scoring model predicts the probability of complications across difficulty levels. Our proposed tumor size threshold (38 mm) improves the quality of the prediction. The model is upgraded by a probability of complications for every difficulty score.

In the original article, the institutional author the E-AHPBA DP-CAR study group was misspelled. It is correct as reflected here. The original article has also been corrected.

Background: Western multicenter studies on distal pancreatectomy with celiac axis resection (DP-CAR), also known as the Appleby procedure, for locally advanced pancreatic cancer are lacking. We aimed to study overall survival, morbidity, mortality and the impact of preoperative hepatic artery embolization (PHAE)., Methods: Retrospective cohort study within the European-African Hepato-Pancreato-Biliary-Association, on DP-CAR between 1-1-2000 and 6-1-2016. Primary endpoint was overall survival. Secondary endpoints were radicality (R0-resection), 90-day mortality, major morbidity, and pancreatic fistulae (grade B/C)., Results: We included 68 patients from 20 hospitals in 12 countries. Postoperatively, 53% of patients had R0-resection, 25% major morbidity, 21% an ISGPS grade B/C pancreatic fistula, and 16% mortality. In total, 82% received (neo-)adjuvant chemotherapy and median overall survival in 62 patients with pancreatic ductal adenocarcinoma patients was 18 months (CI 10-37). We observed no impact of PHAE on ischemic complications., Conclusions: DP-CAR combined with chemotherapy for locally advanced pancreatic cancer is associated with acceptable overall survival. The 90-day mortality is too high and should be reduced. Future studies should investigate to what extent increasing surgical volume or better patient selection can improve outcomes.

Background: In this preliminary study, we investigated the sensitivity and specificity of reverse transcriptase (RT)-qPCR lymph node (LN) metastases detection, the accuracy of intraoperative dye navigation, and the incidence of micrometastasis (MM) detection with this protocol, compared to other published studies., Methods: A total of 23 patients were enrolled in the study. The first stained LN was analyzed using RT-qPCR for carcinoembryonic antigen (CEA) and cytokeratin 20 (CK-20) expression, as markers for MM involvement. The Maruyama computer program was used to determine the most likely first metastatic site. These results were compared with the actual staining patterns to evaluate whether the first draining LN was extracted. We analyzed the correlations between MM and tumor characteristics. The incidence of MM detected with the present method was compared to other studies, as markers of the accuracy of the present protocol., Results: At 35 threshold cycles, the RT-qPCR had a negative predictive value of 100 % and a positive predictive value of 83.3 %. MM were detected in 4 out of 14 node-negative patients (28.6 %). The extracted sentinel LN coincided in 76.9 % of cases with the most probable first metastatic LN predicted by the Maruyama program. MM were found more frequently in these 'high-risk' LNs. Significant differences were found in the Lauren's histological type distribution and the age distribution among the MM-positive and MM-negative groups., Conclusion: Our preliminary results confirm that RT-qPCR is an accurate method of MM detection, that the dye navigation enables the determination of the first draining LN, and that the incidence of MM detection with this focused sentinel LN protocol is comparable to other studies.

Background: Preoperative bowel cleaning for elective colorectal surgery is a routine procedure. Synbiotics (probiotics plus prebiotics) are known for their beneficial effects on gut immune function and maintenance of the gut barrier. The main purpose of this study was to replace preoperative mechanical bowel cleaning with synbiotics and to assess the systemic inflammatory response and clinical outcome in patients undergoing colorectal surgery., Patients and Methods: A prospective double-blind randomized placebo-controlled trial was conducted in 68 patients. The first group of 20 patients received synbiotics, the second group of 28 patients prebiotics and heat-deactivated probiotics, and the third (control) group of 20 patients mechanical bowel cleaning prior to the operation., Results: Significantly higher values of interleukin 6 (IL-6) were detected 72 h after the operation in the synbiotic group (P = 0.025), as well as an increase of fibrinogen at 24 h postoperatively (P = 0.030). No statistical differences were found in leukocytes count, C-reactive protein or the lymphocyte/granulocyte ratio. There were no differences in postoperative complications between the groups. Mean hospital stay was 9.2 days in the prebiotic group, 9.5 days in the control group, and 10.95 days in the synbiotic group., Conclusions: Preoperative administration of prebiotics in elective colorectal surgery appears to have the same protective effect in preventing a postoperative inflammatory response as mechanical bowel cleaning. Further prospective studies are needed to verify the effects of synbiotics.

Aim: The aim of our study was to evaluate the accuracy of preoperative TNM staging with endoscopic ultrasound (EUS) in gastric cancer patients in comparison with the pathohistological stage of the resected specimen, and to determine the possible implications of EUS for individualized treatment of gastric cancer patients at our institution., Patients and Methods: The study included 82 patients operated for resectable gastric cancer between January 1(st) 2001 and July 1(st) 2003 at the Maribor Teaching Hospital Department of Abdominal and General Surgery. The EUS stage was assessed preoperatively at the Endoscopical Unit, and the pathohistological stage in the resected specimen was determined postoperatively at the Department of Pathologic Morphology according to recommended standards., Results: Comparison of EUS and pathohistological assessments revealed accuracy of EUS staging for locoregional tumor infiltration (category T) in 68% of patients. The accuracy of EUS staging was 68% for T1, 69% for T2, 69% for T3 and 60% for T4. Lymph nodes (category N) were correctly staged with EUS in 57% of cases. The EUS stage was correct for lymph nodes with no metastases (N-) in 40% of cases, and for lymph nodes with metastases (N+) in 90%. There was no significant difference in accuracy of EUS staging with regard to tumor site (P = 0.768) or tumor size (P = 0.766)., Conclusions: According to our results the accuracy of EUS staging matched pathohistological staging with regard to tumor infiltration and lymph node stage in 68% and 57% of cases respectively. Underestimation of the final T2 and T3 stages as T1 stage by EUS presents a problem regarding the consistency of EUS examination at our institution, particularly with respect to individual treatment for early gastric cancer. The present uncertainty in EUS stage reliability makes it necessary to have a strategy of radical resection with D2 lymphadenectomy in patients within EUS stages T1-T3, with additional CT examinations in more advanced EUS stages in order to visualize the circumstances of tumor growth. Nevertheless, EUS provides an opportunity for the surgeon to gain more insight into the loco-regional circumstances of the gastric tumor process. For development of individual modes of treatment based on EUS staging, a more reliable assessment of EUS stage is mandatory.

We report a case of acute presentation of a solid pseudopapillary tumor of the pancreas in a young boy who had suffered a blunt abdominal trauma. Urgently performed CT examination and repeated ultrasound revealed a subhepatic mass, which gradually increased in size, but the imaging features were not specific enough to permit a precise diagnosis. Because signs of peritoneal irritation and increased circulatory instability gradually developed within the hours of observation, the decision was made to perform an urgent exploratory laparotomy. The exploration revealed a hematoperitoneum and a large hematoma-like subhepatic bleeding mass. Further exploration showed that this mass was a tumor arising from the head of the pancreas, which had ruptured on the surface. A curative pancreatoduodenectomy was performed. Pathohistological examination of the resected specimen revealed a solid pseudopapillary tumor of the pancreas, an extremely rare tumor predominantly occurring in adolescent girls and in young adult women. It has a favorable prognosis if resected radically. The boy in our report is feeling well 36 months after the operation.