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There is a lack of consensus on the definition of upfront resectability and use of perioperative systemic therapy for colorectal liver metastases (CRLM). This survey aimed to summarize the current treatment strategies for upfront resectable CRLM throughout Europe. A survey was sent to all members of the European-African Hepato-Pancreato-Biliary Association to gain insight into the current views on resectability and the use of systemic therapy for upfront resectable CRLM. The survey was completed by 87 surgeons from 24 countries. The resectability of CRLM is mostly based on the volume of the future liver remnant, while considering tumor biology. Thermal ablation was considered as an acceptable adjunct to resection in parenchymal-sparing CRLM surgery by 77 % of the respondents. A total of 40.2 % of the respondents preferred standard perioperative systemic therapy and 24.1 % preferred standard upfront local treatment. Among the participating European hepato-pancreato-biliary surgeons, there is a high degree of consensus on the definition of CRLM resectability. However, there is much variety in the use of adjunctive thermal ablation. Major variations persist in the use of perioperative systemic therapy in cases of upfront resectable CRLM, stressing the need for further evidence and a consensus. [ABSTRACT FROM AUTHOR]

Major surgery, along with preoperative cholestasis-related complications, are responsible for the increased risk of morbidity and mortality in perihilar cholangiocarcinoma (pCCA). The aim of the present survey is to provide a snapshot of current preoperative management and optimization strategies in Europe. 61 European centers, experienced in hepato-biliary surgery completed a 59-questions survey regarding pCCA preoperative management. Centers were stratified according to surgical caseload (<5 and ≥ 5 cases/year) and preoperative management protocols' application. The overall case volume consisted of 6333 patients. Multidisciplinary discussion was routinely performed in 91.8% of centers. Most respondents (96.7%) recognized the importance of a well-structured preoperative protocol. The preferred method for biliary drainage was percutaneous transhepatic biliary drainage (60.7%) while portal vein embolization was the preferred technique for liver hypertrophy (90.2%). Differences in preoperative pathologic confirmation of malignancy (35.8% vs 28.7%; p < 0.001), number of mismanaged referred patients (88.2% vs 50.8%; p < 0.001), biliary drainage (65.1% vs 55.6%; p = 0.015) and liver function evaluation (37.2% vs 5.6%; p = 0.001) were found between centers according to groups' stratification. The importance of a correct preoperative management is recognized. Nevertheless, the current lack of guidelines leads to wide heterogeneity of behaviors among centers. This survey can provide recommendations to improve pCCA perioperative outcomes. [Display omitted] [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to evaluate whether neoadjuvant therapy (NAT) critically influenced microscopically complete resection (R0) rates and long-term outcomes for patients with pancreatic ductal adenocarcinoma who underwent pancreatoduodenectomy (PD) with portomesenteric vein resection (PVR) from a diverse, world-wide group of high-volume centers., Summary of Background Data: Limited size studies suggest that NAT improves R0 rates and overall survival compared to upfront surgery in R/BR-PDAC patients., Methods: This multicenter study analyzed consecutive patients with R/BR-PDAC who underwent PD with PVR in 23 high-volume centers from 2009 to 2018., Results: Data from 1192 patients with PD and PVR were collected and analyzed. The median age was 68 [interquartile range (IQR) 60-73] years and 52% were males. Some 186 (15.6%) and 131 (10.9%) patients received neoadjuvant chemotherapy (NAC) alone and neoadjuvant chemoradiotherapy, respectively. The R0/R1/R2 rates were 57%, 39.3%, and 3.2% in patients who received NAT compared to 46.6%, 49.9%, and 3.5% in patients who did not, respectively (P =0.004). The 1-, 3-, and 5-year OS in patients receiving NAT was 79%, 41%, and 29%, while for those that did not it was 73%, 29%, and 18%, respectively (P <0.001). Multivariable analysis showed no administration of NAT, high tumor grade, lymphovascular invasion, R1/R2 resection, no adjuvant chemotherapy, occurrence of Clavien-Dindo grade 3 or higher postoperative complications within 90 days, preoperative diabetes mellitus, male sex and portal vein involvement were negative independent predictive factors for OS., Conclusion: Patients with PDAC of the pancreatic head expected to undergo venous reconstruction should routinely be considered for NAT., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: ALPPS is a two-stage hepatectomy that induces more rapid liver growth compared to conventional strategies. This report aims to establish a risk-score to avoid adverse outcomes of ALPPS only for patients with colorectal liver metastases (CRLM) as primary indication for ALPPS., Methods: All patients with CRLM included in the ALPPS registry were included. Risk score analysis was performed for 90-day mortality after ALPPS, defined as death within 90 days after either stage. Two risk scores were generated i.e. one for application before stage-1, and one for application before stage-2. Logistic regression analysis was performed to establish the risk-score., Results: In total, 486 patients were included, of which 35 (7%) died 90 days after stage-1 or 2. In the stage-1 risk score, age ≥67 years (OR 3.7), FLR/BW ratio <0.40 (OR 2.9) and total center-volume (OR 2.4) were included. For the stage-2 score age ≥67 years (OR 3.7), FLR/BW ratio <0.40 (OR 2.8), bilirubin 5 days after stage-1 >50 μmol/L (OR 2.4), and stage-1 morbidity grade IIIA or higher (OR 6.3) were included., Conclusions: The CRLM risk-score to predict mortality after ALPPS demonstrates that older patients with small remnant livers in inexperienced centers, especially after experiencing morbidity after stage-1 have adverse outcomes. The risk score may be used to restrict ALPPS to low-risk patient populations., (Copyright © 2018 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Based on the International ALPPS registry, we have recently proposed two easily applicable risk models (pre-stage1 and 2) for predicting 90-day mortality in ALPPS but a validation of both models has not been performed yet., Methods: The validation cohort (VC) was composed of subsequent cases of the ALPPS registry and cases of centers outside the ALPPS registry., Results: The VC was composed of a total of 258 patients including 70 patients outside the ALPPS registry with 32 cases of early mortalities (12%). Development cohort (DC) and VC were comparable in terms of patient and surgery characteristics. The VC validated both models with an acceptable prediction for the pre-stage 1 (c-statistic 0.64, P = 0.009 vs. 0.77, P < 0.001) and a good prediction for the pre-stage 2 model (c-statistic 0.77, P < 0.001 vs. 0.85, P < 0.001) as compared to the DC. Overall model performance measured by Brier score was comparable between VC and DC for the pre-stage 1 (0.089 vs. 0.081) and pre-stage 2 model (0.079 vs. 0087)., Conclusion: The ALPPS risk score is a fully validated model to estimate the individual risk of patients undergoing ALPPS and to assist clinical decision making to avoid procedure-related early mortality after ALPPS., (Copyright © 2018 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: There has been little focus lately on operative techniques for full graft liver transplantation, and the standard technique is unclear., Methods: An internet survey addressing the key technical issues was e-mailed to programme directors., Results: Responses were obtained from 93 out of 128 (73%) directors contacted. Programmes performed a median of 60 (8-240) transplants per year. Maximum mean cold time of 13 ± 3 h and maximum median steatosis of 40% (15-90%) were tolerated. The inferior vena cava was preserved by 48% of centres all the time and 43% selectively. European centres used temporary portacaval shunting (42%) four times more often than USA programmes. Venous bypass was always used when not preserving the inferior vena cava by less than 25%, and used selectively by approximately 40% of centres. Portal vein anastomosis with room for expansion (88%), graft hepatic artery to native gastroduodenal/common hepatic artery bifurcation (57%) and bile duct-to-duct (47%) were the favoured techniques., Discussion: A standard international operative technique for deceased donor liver transplantation does not exist, although there is a trend towards inferior vena cava preservation. Donor selection criteria were more homogenous across programmes. As suggested by the high response rate, there likely exists interest to investigate technical variations on an international scale., (© 2011 International Hepato-Pancreato-Biliary Association.)

Pancreatic adenocarcinoma remains to have poor prognosis. Most of all patients have locally advanced disease with or without distant disease when diagnosed. Current rationale for the treatment of pancreatic adenocarcinoma in the US and European countries consists of the following formula: (1) accurate staging by improved imaging. (2) a balanced-resection which means not too extensive not too limited. (3) centralized treatment in high-volume center with minimal surgical mortality. (4) surgery alone is not enough for cure and need more radical adjuvant or neoadjuvant therapy. On the other hands, Japanese surgeons had challenged to improve outcome by radical resections but did not show their advantages in terms of survival benefit as shown in recent randomized controlled trials. Now we should look back to surgical role and think 'who can benefit by surgical resection'. The efficacy of "Japanese" radical resection including vascular resection or pancreatic nerve plexus resection should be evaluated, although the devise of novel diagnostic modalities and more effective adjuvant or neoadjuvant therapy are crucial to improve prognosis of this disease.

To overcome the problem of organ shortage in recent years, liver transplantation from a living donor has been established. From a surgical standpoint, split liver transplantation and living-donor liver transplantation (LRLTx) are very complex surgical procedures requiring meticulous surgical techniques. LRLTx was first developed and performed in Asia and the USA. In the beginning of the 1990s, LRLTx was introduced in Europe. In Europe, 46 of 118 registered transplant centres had already performed LRLTx in December 2001. Up to this time point, more than 800 LRLTx were performed since 1991. Medical discussions in the field of LRLTx include the need for high quality procedures, simplifying donor evaluation, optimizing surgical techniques and immunosuppression, all of which are current problems. The perioperative morbidity of the donor including all minor complications is stated to be 10-25%. Biliary complications of 5-10% are the major portion. The results of LRLTx for paediatric and adult recipients are comparable. The perioperative complication rate is slightly higher in LRLTx than after cadaver transplantation. This can be explained by the complexity of the surgical intervention with technical complications and the limited experience so far. Other reasons that can be ascertained are extended indications with higher incidence of tumour recurrence and infectious complications in these recipients. In recent years, LRLTx has emerged as a clinically safe alternative to cadaver transplantation in many cases and has further extended the donor pool. LRLTx has been shown to be a good option for patients with liver disease in which a long waiting time is not permitted.