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BACKGROUND Focal nodular hyperplasia (FNH) and hepatocellular adenoma (HCA) are well-known benign liver lesions. Surgical treatment is usually chosen for symptomatic patients, lesions more than 5 cm, and uncertainty of diagnosis. CASE SUMMARY We described the case of a large liver composite tumor in an asymptomatic 34-year-old female under oral contraceptive for 17-years. The imaging work-out described two components in this liver tumor; measuring 6 cm × 6 cm and 14 cm × 12 cm × 6 cm. The multidisciplinary team suggested surgery for this young woman with an unclear HCA diagnosis. She underwent a laparoscopic left liver lobectomy, with an uneventful postoperative course. Final pathological examination confirmed FNH associated with a large HCA. This manuscript aimed to make a literature review of the current management in this particular situation of large simultaneous benign liver tumors. CONCLUSION The simultaneous presence of benign composite liver tumors is rare. This case highlights the management in a multidisciplinary team setting.

Background Accurate estimation of the hepatic functional reserve before liver resection is important to avoid post-hepatectomy liver failure (PHLF). The aim of the present study was to evaluate the association of indocyanine green retention test with portal pressure by the cause of cirrhosis (non-viral vs. viral) and assessed postoperative outcomes including incidence of PHLF in patients with viral and non-viral cirrhosis. Methods The cohort includes 50 consecutive patients with liver cirrhosis scheduled for liver resection for primary liver tumors at the Lausanne University Hospital between 2009 and 2018. Results There were 31 patients with non-viral liver cirrhosis (Non-virus group) and 19 with viral liver cirrhosis (virus group). The indocyanine green retention rate at 15 min (ICG-R15) (p = 0.276), Hepatic Venous Portal Gradient (HVPG; p = 0.301), and postoperative outcomes did not differ between the non-virus group and viral group. ICG-R15 and HVPG showed a significant linear correlation in all patients (Spearman’s rank correlation coefficient, ρ = 0.599, p ρ = 0.555, p = 0.026), and the virus group (ρ = 0.534, p = 0.007). A receiver operating characteristic curve analysis showed that ICG-R15 was a predictor for presence of portal hypertension (PH; HVPG ≥ 12 mmHg) (area under the curve [AUC] = 0.780). The cut-off value of ICG-R15 for predicting the presence of PH was 16.0% with 72.3% of sensitivity and 79.0% of specificity. Conclusions The ICG-R15 level was associated with portal pressure in both patients with non-virus cirrhosis and patients with virus cirrhosis and predicts the incidence of PH with relatively good discriminatory ability. Clinical trial number https://clinicalTrials.gov(ID:NCT00827723) Local ethics committee number CER-VD 251.08

Fungal infections are generally observed in immunosuppressed patients only, with a diagnostic challenge due to non-specific symptoms. For this reason, appropriate management may be delayed. This case report concerns a 36-year-old man with history of pancreas and kidney transplantation. He had chemotherapy for post-transplant B-cell lymphoma and presented with left upper abdominal pain and fever. Multiple investigations led to a final diagnosis of disseminated abdominal mucormycosis with multiple Rhizomucor abscesses in the liver, spleen and kidney transplant. Treatment was antifungal therapy and laparotomy with splenectomy, wedge resection of two fungal abscesses in segments II and IVb, and segmental left colic resection.

Among the variations of the right hepatic artery (RHA), the identification of an aberrant RHA arising from the gastroduodenal artery (GDA) is vital for avoiding damage to the RHA during surgery, since ligation of the GDA is necessary during pancreaticoduodenectomy (PD). However, this variation is not frequently reported. The purpose of this study was to focus on an aberrant RHA arising from the GDA, which was not noted in the classifications reported by Michels and Hiatt. A total of 574 patients undergoing a PD between Jan 2001 and Dec 2015 at a tertiary care hospital in Switzerland (n = 366) and between Jan 2009 and May 2015 at a hospital in Japan (n = 208) were included in the analysis. Of these, preoperative CT angiography or/and MRI angiography findings were available for 532 patients. We retrospectively analyzed the hepatic artery variations, patient demographics, and surgical outcomes. Among the 532 patients who received a PD, an RHA originating from the GDA was observed in 19 cases (3.5%). Eleven patients (2.1%) had both an aberrant RHA and an aberrant left hepatic artery (LHA) (Hiatt Type 4). Six patients (1.2%) had a replaced CHA arising from the SMA (Hiatt Type 5). We could, therefore, correctly identify the aberration in all cases. We observed rarely reported but important aberrant RHA variations arising from the GDA. To prevent injury during PD in patients with this type of aberrant RHA, intensive preparations using CT and/or MRI imaging before surgery and intraoperative liver Doppler ultrasonography are considered to be essential.

Enhanced recovery after surgery (ERAS) pathway for pancreas has demonstrated its value in clinical practice. However, there is a lack of specific evidence about its application in elderly patients. The aim of the present study was to assess the impact of age on compliance and postoperative outcomes. Patients ≥70 years old that underwent pancreatic resection within an ERAS pathway between 2012 and 2018 were included, and divided into three groups: 70-74, 75-79, and ≥80 years old. Compliance with ERAS items, length of stay, mortality, and complications were analyzed. 114 patients were included: 49, 37, and 28 patients aged 70-74, 75-79, and ≥80 years, respectively. Overall compliance to ERAS items between groups was not different (66%, 66%, and 62%, P = .201). No significant difference was observed in terms of median length of stay (14, 17, and 17 days, P = .717), overall complications (67%, 78%, and 71%, P = .529), major complications (26%, 32%, and 39%, P = .507), or mortality (0%, 3%, and 4%, P = .448) with increasing age. Application of an ERAS pathway is feasible in elderly patients with pancreatic resection. Increasing age was neither associated with poorer compliance nor worse postoperative outcomes.

Introduction Intraductal papillary mucinous neoplasm (IPMN) is a 21st century concept and its management is still controversial. Strong guidelines suggest that surgery is the safest way to prevent malignant evolution. Though the risk of neoplasia is still debated, high-morbidity and mortality surgery must be proposed for high-risk patients to prevent malignant and most likely fatal pancreatic neoplasia. Methods The aim of this study was to analyze histological results of patients who underwent operation for IPMN under the Sendai and Fukuoka guidelines. From January 2005 to August 2016, 491 consecutive patients who underwent pancreatic resection in Lausanne University Hospital were analyzed, including 18 IPMN with surgical indication according to the Sendai and Fukuoka criteria. Results Thirteen (68.4%) patients had benign histopathology after surgery (the non-malignant group). Of the patients with malignant pathology, four (21%) had high-grade dysplasia and two (20.1%) had invasive carcinoma (the malignant group). The median patient age (p = 0.011) and preoperative Carbohydrate Antigen 19–9 (CA19-9) (p = 0.030) were significantly higher in the malignant group than in the non-malignant group. Discussion The use of the current criteria is adequate, but it may be resulting in surgery on excessive numbers of patients with IPMN. A modern decision-making strategy should be based on clinical features, precise imaging data, and biological markers., Highlights • IPMNs are pre-cancerous tumors with a potential evolution to malignant neoplasm. • Revised guidelines can lead to surgical decision but with high morbidity and mortality linked to pancreatic surgery. • Moderns biological markers can help to adjust surgical criteria, added to clinical and imaging features. • More specific criteria are needed prior to resection, and could lead to more and more conservative management.

This retrospective observational study aimed to evaluate whether preoperative sarcopenia, assessed by CT imaging, was associated with postoperative clinical outcomes and overall survival in patients that underwent liver resections. Patients operated on between January 2014 and February 2020 were included. The skeletal muscle index (SMI) was measured at the level of the third lumbar vertebra on preoperative CT scans. Preoperative sarcopenia was defined based on pre-established SMI cut-off values. The outcomes were postoperative morbidity, length of hospital stay (LOS), and overall survival. Among 355 patients, 212 (59.7%) had preoperative sarcopenia. Patients with sarcopenia were significantly older (63.5 years) and had significantly lower BMIs (23.9 kg/m2) than patients without sarcopenia (59.3 years, p < 0.01, and 27.7 kg/m2, p < 0.01, respectively). There was no difference in LOS (8 vs. 8 days, p = 0.75), and the major complication rates were comparable between the two groups (11.2% vs. 11.3%, p = 1.00). The median overall survival times were comparable between patients with sarcopenia and those without sarcopenia (15 vs. 16 months, p = 0.87). Based on CT assessment alone, preoperative sarcopenia appeared to have no impact on postoperative clinical outcomes or overall survival in patients that underwent liver resections. Future efforts should also consider muscle strength and physical performance, in addition to imaging, for preoperative risk stratification.

Simple Summary Cancer cachexia often includes sarcopenia, which is characterized by a progressive, generalized loss of skeletal muscle mass and strength, combined with fatty infiltration into the muscle. Sarcopenia has been considered a patient-specific imaging biomarker for predicting outcomes after cancer surgery. The present study aimed to evaluate whether preoperative sarcopenia was associated with postoperative outcomes and survival in patients that underwent liver resections. Sarcopenia, assessed by preoperative CT imaging, was present in two-thirds of patients. Independent risk factors for sarcopenia were age, male sex, ASA score ≥ 3, and malignancies. Based on CT assessment alone, sarcopenia had no impact on clinical outcomes or overall survival after hepatectomy. Abstract This retrospective observational study aimed to evaluate whether preoperative sarcopenia, assessed by CT imaging, was associated with postoperative clinical outcomes and overall survival in patients that underwent liver resections. Patients operated on between January 2014 and February 2020 were included. The skeletal muscle index (SMI) was measured at the level of the third lumbar vertebra on preoperative CT scans. Preoperative sarcopenia was defined based on pre-established SMI cut-off values. The outcomes were postoperative morbidity, length of hospital stay (LOS), and overall survival. Among 355 patients, 212 (59.7%) had preoperative sarcopenia. Patients with sarcopenia were significantly older (63.5 years) and had significantly lower BMIs (23.9 kg/m2) than patients without sarcopenia (59.3 years, p < 0.01, and 27.7 kg/m2, p < 0.01, respectively). There was no difference in LOS (8 vs. 8 days, p = 0.75), and the major complication rates were comparable between the two groups (11.2% vs. 11.3%, p = 1.00). The median overall survival times were comparable between patients with sarcopenia and those without sarcopenia (15 vs. 16 months, p = 0.87). Based on CT assessment alone, preoperative sarcopenia appeared to have no impact on postoperative clinical outcomes or overall survival in patients that underwent liver resections. Future efforts should also consider muscle strength and physical performance, in addition to imaging, for preoperative risk stratification.

Purpose: Hepatic and/or portal vein embolization are performed before hepatectomy for patients with insufficient future liver remnant and usually achieved with a trans-hepatic approach. The aim of the present study is to describe a modified trans-venous liver venous deprivation technique (mLVD), avoiding the potential risks and limitations of a percutaneous approach to hepatic vein embolization, and to assess the safety, efficacy, and surgical outcome after mLVD.Materials and Methods: Retrospective single-center institutional review board-approved study. From March 2016 to June 2019, consecutive oncologic patients with combined portal and hepatic vein embolization were included. CT volumetric analysis was performed before and after mLVD to assess liver hypertrophy. Complications related to mLVD and surgical outcome were obtained from medical records.Results: Thirty patients (62.7 ± 14.5 years old, 20 men) with liver metastasis (60%) or primary liver cancer (40%) underwent mLVD. Twenty-one patients (70%) had hepatic vein anatomic variants. Technical success of mLVD was 100%. Four patients had complications (three minor and one major). FLR hypertrophy was 64.2% ± 51.3% (mean ± SD). Twenty-four patients (80%) underwent the planned hepatectomy and no surgery was canceled as a consequence of mLVD complications or insufficient hypertrophy. Fifty percent of patients (12/24) had no or mild complications after surgery (Clavien-Dindo 0–II), and 45.8% (11/24) had more serious complications (Clavien-Dindo III–IV). Thirty-day mortality was 4.2% (1/24).Conclusion: mLVD is an effective method to induce FLR hypertrophy. This technique is applicable in a wide range of oncologic situations and in patients with complex right liver vein anatomy.

BACKGROUND The current study aimed to assess the performance of the 3-level complexity classification that stratified liver resection procedures into 3 complexity grades (grade I, low; grade II, intermediate; and grade III, high complexity) and to evaluate whether the Enhanced Recovery after Surgery (ERAS) protocol improves postoperative outcomes for each complexity grade. STUDY DESIGN Consecutive patients undergoing open liver resection and laparoscopic liver resection at Lausanne University Hospital during 2010 to 2020 were assessed. RESULTS A total of 437 patients were included. Operative time, estimated blood loss, and length of hospital stay increased significantly, with a stepwise increase of the grades from I to III in open liver resection and laparoscopic liver resection (all, p < 0.05). The same trend for Comprehensive Complication Index was found in open liver resection (p < 0.005). Age (p = 0.004), 3-level complexity classification (grade II vs I; p = 0.001; grade III vs I; p < 0.001), no use of the ERAS protocol (p = 0.016), and biliary reconstruction (p < 0.001) were significant predictors for postoperative complication, defined as Comprehensive Complication Index ≥ 26.2 in a multivariable logistic regression analysis. The prediction model incorporating the 4 factors had a calculated Concordance Index of 0.735 and 0.742 based on the bootstrapping method. The use of ERAS protocol was associated with lower probability of postoperative complication for each complexity grade and age. CONCLUSIONS The use of ERAS protocol can decrease the probability of postoperative complication for each surgical complexity of liver resection and patient age. This finding emphasized the importance of tailoring perioperative management according to surgical complexity and patient age to improve outcomes after liver resection.

Introduction and importance Synchronous malignancies of gallbladder and biliary tree are together rare entity whose pathogenesis is yet unknown. We report the case of a triple synchronous cancer of 3 distinct location: gallbladder, common bile duct (CBD) and papilla of Vater. Case presentation An 84-years-old woman, was admitted to our Hospital with clinics features of obstructive jaundice. Dilatation of the biliary tree and CBD without evidence of gallstones was seen at US. CT scan confirmed distal CBD obstruction. An endo-US showed a nodule of the head of pancreas infiltrating the lower CBD. Finally, hepatic-MRI displayed a gallbladder malignancy with invasion of CBD. Preoperative staging showed 3 diagnostic suspicions: carcinoma of CBD on CT, pancreatic carcinoma on endo-US and malignancy of gallbladder on MRI. A cephalic duodenopancreatectomy and radical gallbladder resection was performed. Final pathology revealed 3 distinct location of moderately differentiated adenocarcinomas: Gallbladder, CBD and Vater's papilla. Microscopic examination didn't detect any direct continuity between the 3 tumors. Metastases were identified in the pancreaticoduodenal, peri-hepatic and peri-gastric lymph nodes. Clinical discussion Literature displayed 22 cases of synchronous malignancies of gallbladder and CBD and 1 case of triple cancer with associated Vater's papilla carcinoma. In most of these cases, an association with an anomalous pancreatic-bile duct junction was reported. Although the real incidence remain unknown, it was reported to occur in 5–10% of CBD cancers. Conclusion Suspicion of such combination of cancer should be remembered, especially when preoperative investigations don't allow a precise localization of tumor in the biliary tree., Highlights • Rare case report of biliary tract cancer • Diagnosis and treatment of multiple biliary tumors • Differential diagnosis of biliary tract tumors

Objectives To perform a correlation analysis between histopathology and imaging in patients with previously untreated pancreatic ductal adenocarcinoma (PDAC) and to determine the prognostic values of clinical, histological, and imaging parameters regarding overall survival (OS), disease-specific survival (DSS), and progression-free survival (PFS). Methods This single-centre study prospectively included 61 patients (32 males; median age, 68.0 years [IQR, 63.0–75.0 years]) with histologically confirmed PDAC and following surgical resection who preoperatively underwent 18F-FDG PET/CT and DW-MRI. On whole lesions, we measured, using a 42% SUVmax threshold volume of interest (VOI), the following quantitative parameters: mean and maximum standardised uptake values (SUVmean and SUVmax), total lesion glycolysis (TLG), metabolic tumour volume (MTV), mean and minimum apparent diffusion coefficient (ADCmean and ADCmin), diffusion total volume (DTV), and MTV/ADCmin ratio. Spearman’s correlation analysis was performed to assess relationships between these markers and histopathological findings from surgical specimens (stage; grade; resection quality; and vascular, perineural, and lymphatic invasion). Kaplan-Meier and Cox hazard ratio methods were used to evaluate the impacts of imaging parameters on OS (n = 41), DSS (n = 36), and PFS (n = 41). Results Inverse correlations between ADCmin and SUVmax (rho = − 0.34; p = 0.0071), and between SUVmean and ADCmean (rho = − 0.29; p = 0.026) were identified. ADCmin was inversely correlated with tumour grade (rho = − 0.40; p = 0.0015). MTV was an independent predictive factor for OS and DSS, while DTV was an independent predictive factor for PFS. Conclusion In previously untreated PDAC, ADC and SUV values are correlated. Combining PET-MRI metrics may help predict PDAC grade and patients’ survival. Key Points • Minimum apparent diffusion coefficient derived from DW-MRI inversely correlates with tumour grade in pancreatic ductal adenocarcinoma. • In pancreatic ductal adenocarcinoma, metabolic tumour volume has been confirmed as a predictive factor for patients’ overall survival and disease-specific survival. • Combining PET and MRI metrics may help predict grade and patients’ survival in pancreatic ductal adenocarcinoma.

Background The clinical and economic impacts of enhanced recovery after surgery (ERAS) programmes have been demonstrated extensively. Whether ERAS protocols also have a biological effect remains unclear. This study aimed to investigate the biological impact of an ERAS programme in patients undergoing liver surgery. Methods A retrospective analysis of patients undergoing liver surgery (2010–2018) was undertaken. Patients operated before and after ERAS implementation in 2013 were compared. Surrogate markers of surgical stress were monitored: white blood cell count (WBC), C-reactive protein (CRP) level, albumin concentration, and haematocrit. Their perioperative fluctuations were defined as Δvalues, calculated on postoperative day (POD) 0 for Δalbumin and Δhaematocrit and POD 2 for ΔWBC and ΔCRP. Results A total of 541 patients were included, with 223 and 318 patients in non-ERAS and ERAS groups respectively. Groups were comparable, except for higher rates of laparoscopy (24.8 versus 11.2 per cent; P Conclusion Compared with conventional management, implementation of ERAS was associated with an attenuated stress response in patients undergoing liver surgery.

Lausanne University Hospital is in the Francophone part of Switzerland and services a catchment population of about 1 million people. We recorded and analyzed baseline characteristics and surgical outcomes for 400 consecutive patients who underwent liver resection there between January 2014 and February 2020. Their pathological results were primary liver cancer (including hepatocellular carcinoma and intrahepatic cholangiocarcinoma): 21.8%, extrahepatic cholangiocarcinoma (including perihilar cholangiocarcinoma and gallbladder cancer): 5.3%, liver metastases: 51.8%, echinococcosis: 10.8%, adenoma: 3.0%, and other diagnoses: 7.5%. Global morbidity rate (Clavien-Dindo classification ≥ 1) was 45.5% with major complication (Clavien-Dindo classification ≥ 3) identified in 81 patients (20.3%). Of the 400 patients, two died within 30 days of surgery (0.5%) and five died within 90 days (1.3%). The 2017-2019 subgroup had a significantly greater percentage of patients aged ≥ 75 years (20.5%) than did the 2014-2016 subgroup (10.9%; p = 0.011) and a higher percentage of laparoscopic procedures than the earlier subgroup (2014-2016: 9.2%, 2017-2019: 32.5%; p < 0.001). We conclude that as the patient population ages, preoperative management and surgical techniques should be constantly improved.

Optimized fluid management is a key component of enhanced recovery (ERAS) pathways. Implementation is challenging for pancreatoduodenectomy (PD) and clear guidance is missing in the respective protocol. The aim of this retrospective study was to evaluate the influence of perioperative intravenous (IV) fluid administration on postoperative complications. 164 consecutive patients undergoing PD within ERAS between October 2012 and June 2017 were included. Perioperative IV fluid and morbidity (Clavien classification and comprehensive complication index (CCI)) were assessed. A threshold of more than 4400 ml IV fluid during the first 24 h could be identified to predict occurrence of complications (area under ROC curve 0.71), with a positive and negative predictive value of 93 and 23% respectively. More than 4400 ml intravenous fluids during the first 24 h was an independent predictor of overall postoperative complications (adjusted odds ratio 4.40, 95% CI 1.47–13.19; p value = 0.008). Patients receiving ≥ 4400 ml were associated with increased overall complications (94 vs 77%; p value

Background To assess the safety and efficacy of liver venous deprivation (simultaneous hepatic vein embolization with portal vein embolization) compared with portal vein embolization alone before major hepatectomy in patients with small future liver remnant. Methods We assessed all consecutive patients who underwent ipsilateral liver venous deprivation before major hepatectomy (>4 Couinaud’s segments) at the University Hospital Lausanne from 2016 to 2018. Postembolization, volumetric analysis after liver venous deprivation and postoperative outcomes were compared with patients who underwent portal vein embolization alone (portal vein embolization group) from 2010 to 2016. Results During the study period, 21 patients underwent liver venous deprivation and 39 portal vein embolization alone. In the liver venous deprivation versus portal vein embolization groups, dropout rate owing to disease progression was 1 of 21 vs 9 of 39 (P = .053). There were no per procedural complications after liver venous deprivation and no difference in the postoperative outcomes. Future liver remnant hypertrophy was greater in the liver venous deprivation group (median 135%, interquartile range: 123%–154%) than in the portal vein embolization group (median 124%, interquartile range: 107%–140%) at a median time of 22 days after liver venous deprivation vs 26 days after portal vein embolization (P = .034). The median kinetic growth rate was also greater (2.9%/week, interquartile range: 1.9–4.3% vs 1.4%/week, interquartile range: 0.7–2.1%; P Conclusion Ipsilateral liver venous deprivation before major hepatectomy is safe and seems to induce a greater and faster future liver remnant hypertrophy than after portal vein embolization alone. More data are needed to analyze the impact of liver venous deprivation on tumor growth.

Background: Most patients with hepatocellular carcinoma (HCC) have underlying liver disease and a preoperative liver function evaluation is important to avoid postoperative liver failure and death. In Western guidelines, portal hypertension (PH) is listed as a contraindication for liver resection. On the other hand, the indocyanine green retention rate at 15 min (ICG R15) has been widely used in Asian countries for surgical decision making. However, these criteria are based on reports published in the 20th century that included only a small number of patients and were developed empirically. Summary: The number of published case series concerning liver resection in HCC patients with PH has been rapidly increasing since 2011, indicating that liver resection in HCC patients with PH is now routinely performed in specialized centers worldwide. Although PH certainly has an impact and should be considered as a contraindication for major liver resection, it is no longer considered to be a contraindication for minor liver resection, especially laparoscopic liver resection. In addition, new biomarkers and imaging tools to assess preoperative liver function have been extensively reported. The combination of these new factors to well-known risk factors, such as PH and ICG R15, might strengthen the ability to stratify the risk of postoperative liver failure. Key Messages: The present review covers recent topics regarding the assessment of preoperative liver function for surgical decision making in patients with HCC.

Introduction: According to the Barcelona Clinic Liver Cancer (BCLC) algorithm, transarterial chemoembolization (TACE) is recommended in patients with hepatocellular carcinoma (HCC) of intermediate stage (BCLC-B), whereas partial hepatectomy (PH) is restricted to early stage A. Expanding the indication for PH to intermediate stage remains debated. Objective: This meta-analysis aimed to analyze short- and long-term outcomes of PH compared to TACE in patients with intermediate-stage HCC. Methods: A meta-analysis was conducted according to PRISMA guidelines. Trials comparing PH with TACE in patients with intermediate-stage HCC were selected. Only patients of BCLC-B stage were included in the analyses. Primary endpoint was overall survival (OS) and secondary endpoint was 90-day postprocedural mortality. Random-effects models were used to analyze time ratios (TRs). Results: Seven eligible trials were analyzed, including 1,730 BCLC-B patients undergoing PH (n = 750) or TACE (n = 980). Comparison of OS between PH and TACE determined a pooled TR of 1.91 (95% CI 1.24–2.94; p < 0.001). Survival rates at 1-, 3-, and 5-year were 85, 60, and 42% after PH, compared to 73, 60, and 20% after TACE (p < 0.001). There was no difference in postprocedural mortality between PH and TACE with rates of 3.7 and 3.4%, respectively (TR 0.95; 95% CI 0.17–5.50; p = 0.879). Conclusions: In patients with intermediate HCC, PH was associated with increased long-term survival compared to TACE, with comparable postprocedural mortality. These results suggest considering PH as treatment option in intermediate HCC and highlight the urgent need to refine the selection of patients with BCLC-B stage who may benefit from PH.

The aim of the present paper was to describe a new and easy technique for performing pancreaticogastrostomy (PG) through simple pancreatic invagination by a single binding suture without suturing the pancreatic parenchyma. The present study included all consecutive patients who underwent elective pancreaticoduodenectomy from 2007 to 2015. The intraoperative and postoperative outcomes after PG (PG group) were compared with those of patients who underwent pancreaticojejunostomy (PJ) (PJ group). Out of 270 patients, 88 PG and 182 PJ patients were assessed. The rate of clinically significant PF was similar between the PG and PJ groups (10.2% vs. 13.2%, respectively; p = 0.487), despite the risk of pancreatic fistula being higher in the PG group. There were no significant differences in the intraoperative and postoperative outcomes or mortality between the groups. This easy invagination technique for PG is simple, safe and reproducible with a low risk of postoperative pancreatic fistula.

To compare local recurrence (LR) rate in patients with colorectal cancer liver metastasis (CRCLM) after surgical wedge resection (WR) or radiofrequency ablation (RFA) and to investigate predictive factors of LR. This single-centre, retrospective, institutional review board-approved study including 43 consecutive patients with 121 metastases treated by WR and 60 patients with 110 metastases treated by RFA between 2007 and 2014 with 23 and 18.5 months of follow-up, respectively. Demographics and tumour characteristics were compared using the unpaired t-test and chi-square test. Predictive factors for LR (lesion size, depth, relation to hepatic vessels, intervention, margin status) were investigated in uni- and multivariate analyses. Patient and CRCLM characteristics were similar in both groups. Mean lesion size and depth in the WR and RFA groups were 18 mm and 15 mm (p = 0.03), and 19 mm and 26 mm (p < 0.001), respectively. LR showed a trend towards difference in favour of RFA (19% and 10% in the WR and RFA groups, respectively, p = 0.06). Positive margins and lesion depth were predictive factors of LR in the WR group (p = 0.03 and p = 0.02, respectively, on uni- and multivariable analyses). Lesion depth and proximity to a vein increased the risk of positive margins on pathology after WR (p = 0.04 and p < 0.001, respectively). Our analysis did not identify any predictive factors of LR following RFA. Our study showed a trend towards a lower LR rate with RFA compared to WR. Lesions located deep in the liver and/or close to large vessels are at high risk of LR following WR, while curative treatment can be obtained with RFA.

The specific management and outcome of acute biliary pancreatitis in elderly patients is not well established. The aim of this study was to assess the outcome of elderly compared to younger patients after acute biliary pancreatitis. Retrospective analysis of consecutive patients admitted with acute biliary pancreatitis between January 2006 and December 2012. Elderly patients (≥ 70 years) were compared to younger patients (< 70 years) in a case-control study. Comorbidities were assessed according to the Charlson score. Clinical (Atlanta score) and radiological (Balthazar and computed tomography severity index scores) severity were analyzed, as well as clinical outcome. Among 212 patients admitted with acute biliary pancreatitis, 76 were > 70 years (35.8%). Elderly patients had a higher Charlson comorbidity index score at admission (p < 0.001). No difference was observed in terms of clinical and radiological severity of acute pancreatitis. The median hospital stay was longer in elderly (11 days, interquartile range 7-15) than in younger patients (7 days, interquartile range 5-11) (p < 0.001). No difference was observed regarding in-hospital 90-day mortality (3 vs. 1 patients, p = 0.133). Elderly patients had similar clinical and radiological severity of acute biliary pancreatitis compared to younger patients.

Acute kidney injury (AKI) after hepatectomy occurs in around 10% of cases. AKI is often defined based only on postoperative serum creatinine increase. This study aimed to assess if postoperative urine output (UO) correlated with serum creatinine after hepatectomy. All consecutive hepatectomy patients (2010-2016) were assessed. AKI was defined according to KDIGO criteria: serum creatinine increase ≥26.5 μmol/l, creatinine increase ≥1.5x baseline creatinine, or postoperative oliguria. Oliguria was defined as daily mean UO 360 minutes was the only predictor of creatinine increase (HR = 3.6, 95%CI: 1.1-11.4, p = 0.032). Postoperative UO showed poor correlation with postoperative serum creatinine both in all patients and AKI patients. Surgery duration >360 minutes appeared as the only independent predictor of postoperative serum creatinine increase.

Synchronous tumors of the pancreas and gallbladder are rare and often attributed to an abnormal pancreato-biliary junction, which results in a persistent reflux of pancreatic secretions leading to chronic biliary inflammation. We present the case of a 73-year-old woman with synchronous lesions of the pancreas and gallbladder initially considered as two primary localized cancers and treated with curative intent. At relapse, targeted next generation sequencing (NGS), performed in search of potential therapeutic targets, uncovered the fact that the two lesions appeared to be clonally related. This case illustrates the problem of synchronous lesions of the pancreas and gallbladder. New pathologic assessments with comparative molecular analysis of mutational profiles may be helpful in this context.

We read with great interest the article by Sugioka et al, which describes the Glissonean approach based on the concept of Laennec's capsule [1]. We would like to congratulate the authors for their excellent work, comprehensively demonstrating the surgical anatomy of the liver and standardized techniques of the systematic extrahepatic Glissonean pedicle approach. This article is protected by copyright. All rights reserved.

Background The reverse treatment of patients with synchronous colorectal liver metastases (CRLM) is a sequential approach with systemic chemotherapy first, followed by liver resection, and finally, primary tumor resection. The aim of this study was to assess the feasibility, the radiological and pathological tumor response to neoadjuvant therapy, recurrence rates and long-term survival after reverse treatment in a cohort study. Methods Data from patients with CRLM who underwent a reverse treatment from August 2008 to October 2016 were extracted from our prospective hepato-biliary database and retrospectively analyzed for response rates and survival outcomes. Radiological tumor response was assessed by RECIST (Response Evaluation Criteria In Solid Tumor) criteria and pathological response according to TRG (Tumor Regression Grade). Disease-free and overall survival were estimated with Kaplan-Meier survival curves. Results There were 44 patients with 19 rectal and 25 colonic tumors. The reverse treatment was fully completed until primary tumor resection in 41 patients (93%). Radiological assessment after chemotherapy showed 61% of complete/partial response. Pathological tumor response was major or partial in 52% of patients (TRG 1–3). Median disease-free survival after primary tumor resection was 10 months (95% CI 5–15 months). Disease-free survival at 3 and 5 years was 25% and 25%, respectively. Median overall survival was 50 months (95% CI 42–58 months). Overall survival at 3 and 5 years was 59% and 39%, respectively. Conclusion The reverse treatment approach was feasible with a high rate of patients with complete treatment sequence and offers promising long-term survival for selected patients with advanced simultaneous colorectal liver metastases.

BACKGROUND Haemophilia and von Willebrand disease (VWD) are common inherited bleeding disorders. Although patients with haemophilia or VWD have a high risk of hepatitis virus infection and hepatocellular carcinoma (HCC), little is known about the safety of liver resection in these patients. METHODS From 2006 to 2016, there were seven hepatectomies with haemophilia A and three hepatectomies with VWD for malignant liver tumours at tertiary care hospitals in Japan and Switzerland. To evaluate the safety of hepatectomy in the blood coagulation disorder group (BD group), short-term outcomes in these patients were compared with 20 hepatectomies (non-BD group) for HCC, matched to a 2:1, operative procedure, period and background liver. RESULTS Ten liver resections were performed in patients with haemophilia or VWD with administration of recombinant FVIII or VWF concentrate. Comparison of the BD vs non-BD group revealed no significant differences in the operative time (327 vs 407 minutes, P = 0.359), estimated blood loss (730 vs 820 mL, P = 0.748), red blood cell transfusion rate (10.0% vs 5.0%, P = 0.605), major complication rate (Clavien-Dindo grade III or IV) (10.0% vs 5.0%, P = 0.605) or mortality rate (0% vs 0%, P > 0.999). Additionally, the length of the postoperative hospital stay was similar between the two groups (13 vs 14 days, P = 0.296). CONCLUSION Liver resection for treatment of HCC in patients with haemophilia or VWD can be safely performed through an appropriate perioperative administration protocol of coagulation factors.

Recent data has suggested that excessive perioperative weight gain may be associated with adverse outcomes after abdominal surgery, but this observation remains unexplored following liver surgery. The present study aimed to investigate the predictive value of perioperative weight fluctuation in predicting complications after liver surgery. Retrospective monocentric analysis of consecutive patients undergoing liver surgery between 2010 and 2016. Patients without available perioperative weight were excluded. Test variable was postoperative weight change (ΔWeight) measured on day 2 (POD2). Primary outcome was postoperative major morbidity according to Clavien classification (grades III-IV). Secondary outcomes were overall complications, Comprehensive Complication Index (CCI) and length of hospital stay (LoS). Area under the receiver operating characteristic curve (AUROC) and logistic regression with multivariable analysis were performed. A total of 181 patients met the inclusion criteria. Major and overall postoperative complications were reported in 25 (14%) and 87 (48%) patients, respectively. On POD2, median ΔWeight was 2.6 Kg (IQR: 1.1-4.0). Patients with major complications showed increased ΔWeight of 4.2 Kg (IQR: 2.7-5.7), compared to 2.3 Kg (IQR: 0.9-3.7) in patients without major complications (p < 0.001). AUROC of ΔWeight for major complications was 0.74, determining an optimal cut-off of 3.5 Kg, which yielded a negative predictive value of 94%. Multivariable analysis identified ΔWeight ≥3.5 Kg as independent predictor of major complications (OR, 4.73; 95% CI, 1.51-14.80; p = 0.008). ΔWeight ≥3.5 Kg was independently associated with major complications after liver surgery. Perioperative fluctuation of weight appears as an important predictor of adverse outcomes after liver surgery.

International audience; Background: The tumor-expressed CD73 ectonucleotidase generates immune tolerance and promotes invasiveness via adenosine production from degradation of AMP. While anti-CD73 blockade treatment is a promising tool in cancer immunotherapy, a characterization of CD73 expression in human hepatobiliopancreatic system is lacking.Patients and methods: CD73 expression was investigated by immunohistochemistry in a variety of non-neoplastic and neoplastic conditions of the liver, pancreas, and biliary tract.Results: CD73 was expressed in normal hepatobiliopancreatic tissues with subcellular-specific patterns of staining: canalicular in hepatocytes, and apical in cholangiocytes and pancreatic ducts. CD73 was present in all hepatocellular carcinoma (HCC), in all pancreatic ductal adenocarcinoma (PDAC), and in the majority of intra and extrahepatic cholangiocellular carcinomas, whereas it was detected only in a subset of pancreatic neuroendocrine neoplasms and almost absent in acinar cell carcinoma. In addition to the canonical pattern of staining, an aberrant membranous and/or cytoplasmic expression was observed in invasive lesions, especially in HCC and PDAC. These two entities were also characterized by a higher extent and intensity of staining as compared to other hepatobiliopancreatic neoplasms. In PDAC, aberrant CD73 expression was inversely correlated with differentiation (p < 0.01) and was helpful to identify isolated discohesive tumor cells. In addition, increased CD73 expression was associated with reduced overall survival (HR 1.013) and loss of E-Cadherin.Conclusions: Consistent CD73 expression supports the rationale for testing anti-CD73 therapies in patients with hepatobiliopancreatic malignancies. Specific patterns of expression could also be of help in the routine diagnostic workup.

Background: Few data exist on postoperative outcomes of patients with pancreatic body-tail malignancies and tumoral venous invasion (VI). This study aimed at comparing survival and recurrence rate (RR) after distal pancreatectomy for adenocarcinoma in patients with and without tumoral VI. Methods: All consecutive distal pancreatectomies (2000–2015) were collected. Demographics and peri- and postoperative data were recorded. Survivals were calculated using Kaplan-Meier curves. Results: A total of 45 patients underwent distal pancreatectomies for malignancies, of which 33 patients had ductal adenocarcinomas and 2 had cystadenocarcinomas. Among these 35 adenocarcinomas, histological VI was found in 28 patients (80%). Characteristics and intraoperative data of patients with and without VI were similar. Complication rates were 15 of 28 (54%) in the VI group and 3 of 7 (43%) in the group without VI (p = 0.612). Five-year survival for the group with and without VI were 19 and 39% (p = 0.232), respectively. RR was 16 of 28 (57%) for the VI group and 1 of 7 (14%) for the group without VI (p = 0.042). Conclusion: VI did not have an effect on postoperative ­complications. Survivals were similar in case of VI or not. On the contrary, RR was higher in the VI group.

BACKGROUND AND AIMS Hepatobiliary phase (HBP) Gd-EOB-DTPA-enhanced magnetic resonance imaging (MRI) has increased the accuracy in differentiating focal nodular hyperplasia (FNH) and hepatocellular adenoma (HCA). However, the ability of this technique to distinguish HCA subtypes remains controversial. The aim of this study was to investigate the expression of hepatocyte transporters (OATPB1/B3, MRP2, MRP3) in HCA subtypes, hence to understand their MRI signal intensity on HBP Gd-EOB-DTPA-enhanced MRI. METHODS By means of immunohistochemistry (IHC), we scored the expression of OATPB1/B3, MRP2 and MRP3, in resected specimens of FNH (n = 40), subtyped HCA (n = 58) and HCA with focal malignant transformation (HCA-HCC, n = 4). Results were validated on a supplementary set of FNH (n = 6), subtyped HCA (n = 17) and HCA-HCC (n = 1) with Gd-EOB-DTPA MR images. RESULTS All FNH showed a preserved expression of hepatocytes transporters. Beta-catenin-activated HCA (at highest risk of malignant transformation) and HCA-HCC were characterized by preserved/increased OATPB1/B3 expression (predictor of hyperintensity on HBP), as opposed to other HCA subtypes (P

Congenital intrahepatic bile duct dilatation (Caroli's disease) is a rare biliary disease. Although multiple reports exist describing its surgical treatment, relatively few have provided long-term follow-up. Prospective data about 25 cases of monolobular Caroli's disease, with liver resection between 1974 and 2016, were retrospectively analyzed. Patient demographics together with postoperative outcomes and long-term follow-up were assessed. Our 25-patient cohort (average age 53.4 years (range: 27-82)) included 20 cases with disease limited to the left lobe, and 5 to the right. The average time interval between first symptoms and final diagnosis was 5 years (range: 0-34 years). The surgical procedures included left lobectomy in 11 cases, left hepatectomy in 8 cases, right hepatectomy in 3, and sub-segmentectomy in 3 cases. Biliodigestive anastomosis was performed in 7 cases. Complications were observed in 3 patients (25%). Metachronous cholangiocarcinoma was observed in one single case, 10 years after initial operation. In conclusion, surgical treatment for monolobular Caroli's disease is effective, with good short-term results and few complications. Median long-term follow-up was 18 months (range: 3-132), with favorable clinical evolution in 96% of patients.

Few data exist on risk factors (RF) for surgical site infections (SSI) among patients treated in an enhanced recovery after surgery (ERAS) pathway. This study aimed to assess RF for SSI after pancreas surgery in a non-ERAS group and an ERAS cohort. An exploratory retrospective analysis of all pancreas surgeries prospectively collected (01/2000–12/2015) was performed. RF for SSI were calculated using uni- and multivariable binary logistic regressions in non-ERAS and ERAS patients. Pancreas surgery was performed in 549 patients. Among them, 144 presented a SSI (26%). In the non-ERAS group (n = 377), SSI incidence was 27% (99/377), and RF for SSI were male gender and preoperative biliary stenting. Since 2012, 172 consecutive patients were managed within an ERAS pathway. Forty-five patients (26%) had SSI. On multivariable analysis no RF for SSI in the ERAS cohort was found. In the ERAS group, patients with a pathway compliance ≤70% had higher occurrence of SSI (30/45 = 67% vs. 7/127 = 6%, p 70% might diminish the SSI rate.

Portal vein embolization (PVE) has been developed to increase the size of the future remnant liver (FRL) left in place after major hepatectomy, thus reducing the risk of postoperative liver insufficiency. PVE consist in embolizing preoperatively portal branches of the segments that will be resected. Indication is based on preoperative measurements of the FRL by computed tomography and its ratio with either the theoretical liver volume or by direct measurement of the functional liver volume. After PVE, the volume and function of the FRL increases in 3 to 6 weeks, permitting extensive resections in patients otherwise contraindicated for liver resection. The PVE technique is variable from one center to another; however n-butyl-cyano-acrylate provides an interesting compromise between hypertrophy rate and procedure risk.