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BACKGROUND: The use of a simultaneous resection (SIMR) in patients with synchronous colorectal liver metastases (sCRLM) has increased over the past decades. However, it remains unclear when a SIMR is beneficial and when it should be avoided. The aim of this retrospective cohort study was therefore to compare the outcomes of a SIMR for sCRLM in different settings, and to assess which factors are independently associated with unfavorable outcomes.METHODS: To perform this retrospective cohort study, patients with sCRLM undergoing SIMR (2004-2019) were extracted from an international multicenter database, and their outcomes were compared after stratification according to the type of liver and colorectal resection performed. Factors associated with unfavorable outcomes were identified through multivariable logistic regression.RESULTS: Overall, 766 patients were included, encompassing colorectal resections combined with a major liver resection (n=122), minor liver resection in the anterolateral (n=407), or posterosuperior segments ('Technically major', n=237). Minor and technically major resections, compared to major resections, were more often combined with a rectal resection (29.2 and 36.7 vs. 20.5%, respectively, both P=0.003) and performed fully laparoscopic (22.9 and 23.2 vs. 6.6%, respectively, both P = 0.003). Major and technically major resections, compared to minor resections, were more often associated with intraoperative transfusions (42.9 and 38.8 vs. 20%, respectively, both P = 0.003) and unfavorable incidents (9.6 and 9.8 vs. 3.3%, respectively, both P≤0.063). Major resections were associated, compared to minor and technically major resections, with a higher overall morbidity rate (64.8 vs. 50.4 and 49.4%, respectively, both P≤0.024) and a longer length of stay (12 vs. 10 days, both P≤0.042). American Society of Anesthesiologists grades ≥3 [adjusted odds ratio (aOR): 1.671, P=0.015] and undergoing a major liver resection (aOR: 1.788, P=0.047) were independently associated with an increased risk of severe morbidity, while undergoing a left-sided colectomy was associated with a decreased risk (aOR: 0.574, P=0.013).CONCLUSIONS: SIMR should primarily be reserved for sCRLM patients in whom a minor or technically major liver resection would suffice and those requiring a left-sided colectomy. These findings should be confirmed by randomized studies comparing SIMR with staged resections.

Background Limited liver resections (LLRs) for tumours located in the posterosuperior segments of the liver are technically demanding procedures. This study compared outcomes of robotic (R) and laparoscopic (L) LLR for tumours located in the posterosuperior liver segments (IV, VII, and VIII). Methods This was an international multicentre retrospective analysis of patients who underwent R-LLR or L-LLR at 24 centres between 2010 and 2019. Patient demographics, perioperative parameters, and postoperative outcomes were analysed; 1 : 3 propensity score matching (PSM) and 1 : 1 coarsened exact matching (CEM) were performed. Results Of 1566 patients undergoing R-LLR and L-LLR, 983 met the study inclusion criteria. Before matching, 159 R-LLRs and 824 L-LLRs were included. After 1 : 3 PSM of 127 R-LLRs and 381 L-LLRs, comparison of perioperative outcomes showed that median blood loss (100 (i.q.r. 40–200) versus 200 (100–500) ml; P = 0.003), blood loss of at least 500 ml (9 (7.4 per cent) versus 94 (27.6 per cent); P < 0.001), intraoperative blood transfusion rate (4 (3.1 per cent) versus 38 (10.0 per cent); P = 0.025), rate of conversion to open surgery (1 (0.8 per cent) versus 30 (7.9 per cent); P = 0.022), median duration of Pringle manoeuvre when applied (30 (20–46) versus 40 (25–58) min; P = 0.012), and median duration of operation (175 (130–255) versus 224 (155–300); P < 0.001) were lower in the R-LLR group compared with the L-LLR group. After 1 : 1 CEM of 104 R-LLRs with 104 L-LLRs, R-LLR was similarly associated with significantly reduced blood loss and a lower rate of conversion to open surgery. Conclusion Based on a matched analysis of well selected patients, both robotic and laparoscopic access could be undertaken safely with good outcomes for tumours in the posterosuperior liver segments.

BACKGROUND: Preoperative patient selection in Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is not always reliable with currently available scores, particularly in patients with primary liver tumor. This study aims to (I) to determine whether comorbidities and patients characteristics are a risk factor in ALPPS and (II) to create a score predicting 90-day mortality preoperatively. METHODS: Thirteen high-volume centers participated in this retrospective multicentric study. A risk analysis based on patient characteristics, underlying disease and procedure type was performed to identify risk factors and model the Comprehensive ALPPS Preoperative Risk Assessment (CAPRA) score. A nonparametric receiver operating characteristic analysis was performed to estimate the predictive ability of our score against the Charlson Comorbidity Index (CCI), the age-adjusted CCI (aCCI), the ALPPS risk score before Stage 1 (ALPPS-RS1) and Stage 2 (ALPPS-RS2). The model was internally validated applying bootstrapping. RESULTS: A total of 451 patients were included. Mortality was 14.4%. The CAPRA score is calculated based on the following formula: (0.1 × age) − (2 × BSA) + 1 (in the presence of primary liver tumor) + 1 (in the presence of severe cardiovascular disease) + 2 (in the presence of moderate or severe diabetes) + 2 (in the presence of renal disease) + 2 (if classic ALPPS is planned). The predictive ability was 0.837 for the CAPRA score, 0.443 for CCI, 0.519 for aCCI, 0.693 for ALPPS-RS1 and 0.807 for ALPPS-RS2. After 1,000 cycles of bootstrapping the C statistic was 0.793. The accuracy plot revealed a cut-off for optimal prediction of postoperative mortality of 4.70. CONCLUSIONS: Comorbidities play an important role in ALPPS and should be carefully considered when planning the procedure. By assessing the patient’s preoperative condition in relation to ALPPS, the CAPRA score has a very good ability to predict postoperative mortality.

Introduction: Currently, the impact of body mass index (BMI) on the outcomes of laparoscopic liver resections (LLR) is poorly defined. This study attempts to evaluate the impact of BMI on the peri-operative outcomes following laparoscopic left lateral sectionectomy (L-LLS). Methods: A retrospective analysis of 2183 patients who underwent pure L-LLS at 59 international centers between 2004 and 2021 was performed. Associations between BMI and selected peri-operative outcomes were analyzed using restricted cubic splines. Results: A BMI of >27kg/m2 was associated with increased in blood loss (Mean difference (MD) 21 mls, 95% CI 5–36), open conversions (Relative risk (RR) 1.13, 95% CI 1.03–1.25), operative time (MD 11 min, 95% CI 6–16), use of Pringles maneuver (RR 1.15, 95% CI 1.06–1.26) and reductions in length of stay (MD -0.2 days, 95% CI -0.3 to −0.1). The magnitude of these differences increased with each unit increase in BMI. However, there was a “U” shaped association between BMI and morbidity with the highest complication rates observed in underweight and obese patients. Conclusion: Increasing BMI resulted in increasing difficulty of L-LLS. Consideration should be given to its incorporation in future difficulty scoring systems in laparoscopic liver resections.

Left lateral sectionectomy (LLS) is one of the most commonly performed minimally invasive liver resections. While laparoscopic (L)-LLS is a well-established technique, over traditional open resection, it remains controversial if robotic (R)-LLS provides any advantages of L-LLS.A post hoc analysis of 997 patients from 21 international centres undergoing L-LLS or R-LLS from 2006 to 2020 was conducted. A total of 886 cases (214 R-LLS, 672 L-LLS) met study criteria. 1:1 and 1:2 propensity score matched (PSM) comparison was performed between R-LLSL-LLS. Further subset analysis by Iwate difficulty was also performed. Outcomes measured include operating time, blood loss, open conversion, readmission rates, morbidity and mortality.Comparison between R-LLS and L-LLS after PSM 1:2 demonstrated statistically significantly lower open conversion rate in R-LLS than L-LLS (0.6% versus 5%, p = 0.009) and median blood loss was also statistically significantly lower in R-LLS at 50 (80) versus 100 (170) in L-LLS (p = 0.011) after PSM 1:1 although there was no difference in the blood transfusion rate. Pringle manoeuvre was also found to be used more frequently in R-LLS, with 53(24.8%) cases versus to 84(12.5%) L-LLS cases (p 0.001). There was no significant difference in the other key perioperative outcomes such as operating time, length of stay, postoperative morbidity, major morbidity and 90-day mortality between both groups.R-LLS was associated with similar key perioperative outcomes compared to L-LLS. It was also associated with significantly lower blood loss and open conversion rates compared to L-LLS.

Estimation of physiologic ability and surgical stress system (E-PASS) has been shown to be effective in predicting morbidity after surgery for perihilar cholangiocarcinoma (PHCC). Nevertheless, E-PASS does not include an assessment of the disease specific risk factors. The aim of the study was to estimate the combined impact of E-PASS and specific preoperative factors on major morbidity for PHCC patients.A retrospective analysis of a prospectively collected data was performed. Severe morbidity according to complication comprehensive index was defined as ≥40 points. A value of comprehensive risk score (CRS) ≥1 was taken as critical.Multivariate analysis of perioperative data from 122 patients revealed significant impact of five factors (CRS ≥1, future liver remnant volume50%, T4 stage, moderate and severe cholangitis, INR) on the risk of severe morbidity after resection. The AUC for the combination of these factors was classified as good predictive value (0.810, 95% CI 0.729-0.891) and poor predictive value (0.673, 95% CI 0.573-0.773) for CRS alone (p = 0.040).A combination of E-PASS with disease specific risk factors is a reliable predictive model for major morbidity for patients undergoing radical surgery for PHCC.

The diffusion of laparoscopic radical surgery for hydatid liver echinococcosis remains limited. There are no published data on a comparative analysis of the immediate and long-term results of radical and conservative laparoscopic surgery for liver hydatid cysts. Comparison of the immediate and long-term outcomes after laparoscopic radical and conservative cystectomies was aimed. HPB center (Center 1) and general surgery hospital in an endemic area (Center 2) participated in a retrospective study. Radical surgery included total, subtotal pericystectomy, and liver resection. Conservative surgery comprised cystectomy without/with partial pericystectomy. The total number of patients who underwent surgery for liver hydatid cysts was 213. Laparoscopic cystectomy was performed in 106 (50%) patients. This number included 47 radical laparoscopic cystectomy (Center 1). Conservative laparoscopic procedures were used in 59 patients (Center 2). Finally, twenty-seven pairs of patients were matched. Immediate outcomes were better for radical treatment in terms of severe morbidity, length of hospital stay, and time of abdominal drainage before and after PSM. The mean follow-up length was 23 (4–66) and 29 (6–66) months and the recurrence rate was 2% and 5% in groups of radical and conservative treatment respectively. No differences were found in 1-, 3-, and 5-year disease free survival. After second PSM for recurrence, 20 pairs were matched with no relapse of disease. Laparoscopic radical surgery leads to the better immediate outcomes and can be recommended as the preferred treatment option in a specialized HPB center. Conservative option is justified in general hospitals in endemic area for selected uncomplicated cysts.

Controversies exist among liver surgeons regarding clinical outcomes of the laparoscopic versus the robotic approach for major complex hepatectomies. The authors therefore designed a study to examine and compare the perioperative outcomes of laparoscopic left hepatectomy or extended left hepatectomy (L-LH/L-ELH) versus robotic left hepatectomy or extended left hepatectomy (R-LH/R-ELH) using a large international multicenter collaborative database.An international multicenter retrospective analysis of 580 patients undergoing L-LH/L-ELH or R-LH/R-ELH at 25 specialized hepatobiliary centers worldwide was undertaken. Propensity score-matching (PSM) was used at a 1:1 nearest-neighbor ratio according to 15 perioperative variables, including demographics, tumor characteristics, Child-Pugh score, presence of portal hypertension, multiple resections, histologic diagnosis, and Iwate difficulty grade.Before the PSM, 190 (32 %) patients underwent R-LH/R-ELH, and 390 (68 %) patients underwent L-LH/L-ELH. After the matching, 164 patients were identified in each arm without significant differences in demographics, preoperative variables, medical history, tumor pathology, tumor characteristics, or Iwate score. Regarding intra- and postoperative outcomes, the rebotic approach had significantly less estimated blood loss (EBL) (100 ml [IQR 200 ml] vs 200 ml [IQR 235 ml]; p = 0.029), fewer conversions to open operations (n = 4 [2.4 %] vs n = 13, [7.9 %]; p = 0.043), and a shorter hospital stay (6 days [IQR 3 days] vs 7 days [IQR 3.3 days]; p = 0.009).Both techniques are safe and feasible in major hepatic resections. Compared with L-LH/L-ELH, R-LH/R-ELH is associated with less EBL, fewer conversions to open operations, and a shorter hospital stay.

The article presents an analysis of the results of the three most important international consensus conferences on the development, dissemination, assessment of the efficacy and safety of laparoscopic liver resection (2008, 2014 and 2017). An analysis of world experience has demonstrated the slow but steady diffusion of the new technology. It is proved that the immediate outcomes of laparoscopic liver resection are superior to those for open resections, and the long-term results do not differ in the treatment of the most common oncological and benign liver tumors in selected patients. Unlike laparoscopic surgery of other organs of the abdominal cavity, many issues regarding the technology, safety and reproducibility of the operation did not receive a final solution due to the slower data set and other objective obstacles associated primarily with the complexity of the surgical anatomy of the liver. In this regard, a clear achievement of the expert's work should be considered a clear definition of the strategy for mastering the technology of laparoscopic liver resection, as well as selection of patients to avoid serious errors and discrediting the method. All conferences remained in line with the initially emerging trends, adding more evidence-based research to confirm and refine the capabilities of the technology. There is still a shortage of prospective randomized trials and large national and international registries. Further analysis of experience in this direction will allow us to correct the previously obtained data and more clearly indicate the role and place of laparoscopic liver resection in the arsenal of methods of modern surgical hepatology.

Laparoscopic liver resection (LLR) of posterosuperior segments (PSS) is still technically demanding procedure for highly selective patients. There is no long-term survival comparative estimation after LLR and open liver resection (OLR) for colorectal liver metastases (CRLM) located in PSS. We aimed to compare long-term overall (OS) and disease-free survival (DFS) after parenchyma-sparing LLR with expanding indications and open liver resection (OLR) of liver PSS in patients with CRLM. Two Russian centers took part in the study. Patients with missing data, hemihepatectomy and extrahepatic tumors were excluded. One of contraindications for LLR was suspicion for tumor invasion in large hepatic vessels. Logistic regression was used for 1:1 propensity score matching (PSM). PSS were resected in 77 patients, which accounted for 42% of the total number of liver resections for CRLM. LLR were performed in 51 (66%) patients. Before and after matching, no differences were found between groups in the following factors: median size of the largest metastatic tumor; proximity to the large liver vessels; the rate of anatomical parenchyma sparing resection of PSS; a positive response to chemotherapy before and after surgery. Regardless of matching, the size of the largest metastases was above 50 mm in more than one-third of patients who received LLR. Before matching, intraoperative blood loss, ICU stay and hospital stay were significantly greater in the group of OLR. No 90-day mortality was observed within both groups. There were no differences in long-term oncological outcomes: 5-year OS after PSM was 78% and 63% after LLR and OLR, respectively; 4-year DFS after PSM was 27% in both groups. Laparoscopic parenchyma-sparing resection of PSS for CRLM are justified in majority of patients who have an indication for OLR if performed in high volume specialized centers expertized in laparoscopic liver surgery.

Background: Despite the rapid advances that minimally invasive liver resection has gained in recent decades, open conversion is still inevitable in some circumstances. In this study, we aimed to determine the risk factors for open conversion after minimally invasive left lateral sectionectomy, and its impact on perioperative outcomes. Methods: This is a post hoc analysis of 2,445 of 2,678 patients who underwent minimally invasive left lateral sectionectomy at 45 international centers between 2004 and 2020. Factors related to open conversion were analyzed via univariate and multivariate analyses. One-to-one propensity score matching was used to analyze outcomes after open conversion versus non-converted cases. Results: The open conversion rate was 69/2,445 (2.8%). On multivariate analyses, male gender (3.6% vs 1.8%, P = .011), presence of clinically significant portal hypertension (6.1% vs 2.6%, P = .009), and larger tumor size (50 mm vs 32 mm, P < .001) were identified as independent factors associated with open conversion. The most common reason for conversion was bleeding in 27/69 (39.1%) of cases. After propensity score matching (65 open conversion vs 65 completed via minimally invasive liver resection), the open conversion group was associated with increased operation time, blood transfusion rate, blood loss, and postoperative stay compared with cases completed via the minimally invasive approach. Conclusion: Male sex, portal hypertension, and larger tumor size were predictive factors of open conversion after minimally invasive left lateral sectionectomy. Open conversion was associated with inferior perioperative outcomes compared with non-converted cases.

The role of laparoscopy in the treatment of intrahepatic cholangiocarcinoma (ICC) remains unclear. This multicenter study examined the outcomes of laparoscopic liver resection for ICC. Patients with ICC who had undergone laparoscopic or open liver resection between 2012 and 2019 at four European expert centers were included in the study. Laparoscopic and open approaches were compared in terms of surgical and oncological outcomes. Propensity score matching was used for minimizing treatment selection bias and adjusting for confounders (age, ASA grade, tumor size, location, number of tumors and underlying liver disease). Of 136 patients, 50 (36.7%) underwent laparoscopic resection, whereas 86 (63.3%) had open surgery. Median tumor size was larger (73.6 vs 55.1 mm, p = 0.01) and the incidence of bi-lobar tumors was higher (36.6 vs 6%, p < 0.01) in patients undergoing open surgery. After propensity score matching baseline characteristics were comparable although open surgery was associated with a larger fraction of major liver resections (74 vs 38%, p < 0.01), lymphadenectomy (60 vs 20%, p < 0.01) and longer operative time (294 vs 209 min, p < 0.01). Tumor characteristics were similar. Laparoscopic resection resulted in less complications (30 vs 52%, p = 0.025), fewer reoperations (4 vs 16%, p = 0.046) and shorter hospital stay (5 vs 8 days, p < 0.01). No differences were found in terms of recurrence, recurrence-free and overall survival. Laparoscopic resection seems to be associated with improved short-term and with similar long-term outcomes compared with open surgery in patients with ICC. However, possible selection criteria for laparoscopic surgery are yet to be defined.

Objective: to reach global expert consensus on the definition of TOLS in minimally invasive and open liver resection among renowned international expert liver surgeons using a modified Delphi method.Summary background data: textbook outcome is a novel composite measure combining the most desirable postoperative outcomes into one single measure and representing the ideal postoperative course. Despite a recently developed international definition of Textbook Outcome in Liver Surgery (TOLS), a standardized and expert consensus-based definition is lacking.Methods: this international, consensus-based, qualitative study used a Delphi process to achieve consensus on the definition of TOLS. The survey comprised 6 surgical domains with a total of 26 questions on individual surgical outcome variables. The process included 4 rounds of online questionnaires. Consensus was achieved when a threshold of at least 80% agreement was reached. Results from the Delphi rounds were used to establish an international definition of TOLS.Results: in total, 44 expert liver surgeons from 22 countries and all three major international hepato-pancreato-biliary associations completed round 1. Forty-two (96%), 41 (98%) and 41 (98%) of the experts participated in round 2, 3 and 4, respectively. The TOLS definition derived from the consensus process included the absence of intraoperative grade ≥2 incidents, postoperative bile leakage grade B/C, postoperative liver failure grade B/C, 90-day major postoperative complications, 90-day readmission due to surgery-related major complications, 90-day/in-hospital mortality and the presence of R0 resection margin.Conclusions: this is the first study providing an international expert consensus-based definition of TOLS for minimally invasive and open liver resections by use of a formal Delphi consensus approach. TOLS may be useful in assessing patient-level hospital performance and carrying out international comparisons between centers with different clinical practices to further improve patient outcomes.

Background: Despite the worldwide increase of both obesity and the use of minimally invasive liver surgery (MILS), evidence regarding the safety and eventual benefits of MILS in obese patients is scarce. The aim of this study was therefore to compare the outcomes of non-obese and obese patients (BMI 18.5-29.9 and BMI≥30, respectively) undergoing MILS and OLS, and to assess trends in MILS use among obese patients.Methods: In this retrospective cohort study, patients operated at 20 hospitals in eight countries (2009-2019) were included and the characteristics and outcomes of non-obese and obese patients were compared. Thereafter, the outcomes of MILS and OLS were compared in both groups after propensity-score matching (PSM). Changes in the adoption of MILS during the study period were investigated.Resuls: Overall, 9963 patients were included (MILS: n = 4687; OLS: n = 5276). Compared to non-obese patients (n = 7986), obese patients(n = 1977) were more often comorbid, less often received preoperative chemotherapy or had a history of previous hepatectomy, had longer operation durations and more intraoperative blood loss (IOBL), paralleling significantly higher rates of wound- and respiratory-related complications. After PSM, MILS, compared to OLS, was associated, among both non-obese and obese patients, with less IOBL (200 ml vs 320 ml, 200 ml vs 400 ml, respectively), lower rates of transfusions (6.6% vs 12.8%, 4.7% vs 14.7%), complications (26.1% vs 35%, 24.9% vs 34%), bile leaks(4% vs 7%, 1.8% vs 4.9%), liver failure (0.7% vs 2.3%, 0.2% vs 2.1%), and a shorter length of stay(5 vs 7 and 4 vs 7 days). A cautious implementation of MILS over time in obese patients (42.1%-53%, p < .001) was paralleled by stable severe morbidity (p = .433) and mortality (p = .423) rates, despite an accompanying gradual increase in surgical complexity.Conclusions: MILS is increasingly adopted and associated with perioperative benefits in both non-obese and obese patients.

Currently, the strategy for preoperative management of patients with malignant obstructive jaundice is not defined. The indications for biliary drainage procedures, the choice of biliary drainage technique and duration of preoperative drainage are still disputable. Analysis of international trials revealed that routine preoperative biliary drainage procedures are not recommended. The indications for biliary drainage in resectable tumors are determined considering severity of obstructive jaundice, cholangitis, dates of major surgery and Bismuth-Corlette tumor type in case of proximal biliary stricture. The choice of retrograde or antegrade preoperative biliary drainage depends on the type of biliary stricture (distal or proximal) and possibilities of medical institution. The majority of studies showed that retrograde (endoscopic) biliary drainage procedures are preferred for distal strictures, antegrade (transhepatic) – for proximal ones. Duration of preoperative biliary drainage depends on normalization of biochemical values. Prolonged drainage may be followed by increased incidence of early postoperative complications. The optimal period of preoperative biliary drainage is 2 weeks. It is necessary to determine the causes of obstructive jaundice as early as possible for successful treatment. This is also essential to define optimal treatment strategy in certain case. Advisability and certain technique of biliary decompression should be determined in accordance with the chosen treatment strategy.

Contains fulltext : 245473.pdf (Publisher’s version ) (Open Access) BACKGROUND: Resection for perihilar cholangiocarcinoma (pCCA) in primary sclerosing cholangitis (PSC) has been reported to lead to worse outcomes than resection for non-PSC pCCA. The aim of this study was to compare prognostic factors and outcomes after resection in patients with PSC-associated pCCA and non-PSC pCCA. METHODS: The international retrospective cohort comprised patients resected for pCCA from 21 centres (2000-2020). Patients operated with hepatobiliary resection, with pCCA verified by histology and with data on PSC status, were included. The primary outcome was overall survival. Secondary outcomes were disease-free survival and postoperative complications. RESULTS: Of 1128 pCCA patients, 34 (3.0%) had underlying PSC. Median overall survival after resection was 33 months for PSC patients and 29 months for non-PSC patients (p = .630). Complications (Clavien-Dindo grade ≥ 3) were more frequent in PSC pCCA (71% versus 44%, p = .003). The rate of posthepatectomy liver failure (21% versus 17%, p = .530) and 90-day mortality (12% versus 13%, p = 1.000) was similar for PSC and non-PSC patients. CONCLUSION: Median overall survival after resection for pCCA was similar in patients with underlying PSC and non-PSC patients. Complications were more frequent after resection for PSC-associated pCCA, with no difference in postoperative mortality.

Background Minimally invasive right posterior sectionectomy (RPS) is a technically challenging procedure. This study was designed to determine outcomes following robotic RPS (R-RPS) and laparoscopic RPS (L-RPS). Methods An international multicentre retrospective analysis of patients undergoing R-RPS versus those who had purely L-RPS at 21 centres from 2010 to 2019 was performed. Patient demographics, perioperative parameters, and postoperative outcomes were analysed retrospectively from a central database. Propensity score matching (PSM) was performed, with analysis of 1 : 2 and 1 : 1 matched cohorts. Results Three-hundred and forty patients, including 96 who underwent R-RPS and 244 who had L-RPS, met the study criteria and were included. The median operating time was 295 minutes and there were 25 (7.4 per cent) open conversions. Ninety-seven (28.5 per cent) patients had cirrhosis and 56 (16.5 per cent) patients required blood transfusion. Overall postoperative morbidity rate was 22.1 per cent and major morbidity rate was 6.8 per cent. The median postoperative stay was 6 days. After 1 : 1 matching of 88 R-RPS and L-RPS patients, median (i.q.r.) blood loss (200 (100–400) versus 450 (200–900) ml, respectively; P 500 ml; P = 0.001), need for intraoperative blood transfusion (10.2 versus 23.9 per cent, respectively; P = 0.014), and open conversion rate (2.3 versus 11.4 per cent, respectively; P = 0.016) were lower in the R-RPS group. Similar results were found in the 1 : 2 matched groups (66 R-RPS versus 132 L-RPS patients). Conclusion R-RPS and L-RPS can be performed in expert centres with good outcomes in well selected patients. R-RPS was associated with reduced blood loss and lower open conversion rates than L-RPS.

Background Percutaneous radiofrequency‐assisted liver partition with portal vein embolization in staged liver resection (PRALPPS) represents an alternative to portal vein embolization (PVE) followed by major liver resection in patients with perihilar cholangiocarcinoma. Methods This was an observational case–control study. Both procedures were applied in patients with a future liver remnant (FLR) volume of less than 40 per cent. The main end points of the study were short‐term morbidity and mortality for the two procedures. The study also compared the efficacy of the preresection phases estimated by kinetic growth rate (KGR), time interval and degree of hypertrophy of the FLR. Results The first phase (preresection) was completed in 11 and 18 patients, and the second phase (resection) in nine and 14 patients, in the PRALPPS and PVE groups respectively. Major morbidity after the first stage did not differ between the groups. There were no differences in blood loss, severe morbidity or liver failure rate after the second stage, with no deaths. The mean KGR of the FLR after the preresection phase for PRALPPS was 3·8 (0·6–9·8) per cent/day, and that after PVE was 1·8 (0–6·7) per cent/day (P = 0·037). The mean time interval for FLR hypertrophy in the PRALPPS and PVE groups was 15 (6–29) and 20 (8–35) days respectively (P = 0·039). Conclusion Short‐term outcomes were similar for PRALPPS and PVE in terms of safety. Remnant hypertrophy was achieved more rapidly by PRALPPS., Percutaneous radiofrequency‐assisted liver partition with portal vein embolization in staged liver resection (PRALPPS), modIfied ALPPS with reduced surgical trauma on the first stage, was used in 11 patients with perihilar cholangiocarcinoma. PRALPPS did not differ from portal vein embolization (PVE) in terms of morbidity or mortality. The kinetic growth rate and mean time interval for future liver remnant hypertrophy in the PRALPPS group were significantly better than those in the PVE group. Similar complication rates and outcomes

Objective. To estimate the short-term results of modified variant of ALPPS (PRALPPS) in patients with perihilar and intrahepatic cholangiocarcinoma.Material and methods. Procedure was indicated for future liver remnant Results. PRALPPS was applied in 13 patients and completed in 10 patients. Degree of hypertrophy and kinetic growth rate were 48 and 4.3%/day respectively. Major morbidity (>II) after the stage 1 and 2 was presented in 3 (only IIIa) and 7 patients, respectively.Conclusion. PRALPPS may be considered as an effective and safe procedure in patients with perihilar and intrahepatic cholangiocarcinoma.

Background A shift towards parenchymal-sparing liver resections in open and laparoscopic surgery emerged in the last few years. Laparoscopic liver resection is technically feasible and safe, and consensus guidelines acknowledge the laparoscopic approach in the posterosuperior segments. Lesions situated in these segments are considered the most challenging for the laparoscopic approach. The aim of this trial is to compare the postoperative time to functional recovery, complications, oncological safety, quality of life, survival and costs after laparoscopic versus open parenchymal-sparing liver resections in the posterosuperior liver segments within an enhanced recovery setting. Methods The ORANGE Segments trial is an international multicentre randomised controlled superiority trial conducted in centres experienced in laparoscopic liver resection. Eligible patients for minor resections in the posterosuperior segments will be randomised in a 1:1 ratio to undergo laparoscopic or open resections in an enhanced recovery setting. Patients and ward personnel are blinded to the treatment allocation until postoperative day 4 using a large abdominal dressing. The primary endpoint is time to functional recovery. Secondary endpoints include intraoperative outcomes, length of stay, resection margin, postoperative complications, 90-day mortality, time to adjuvant chemotherapy initiation, quality of life and overall survival. Laparoscopic liver surgery of the posterosuperior segments is hypothesised to reduce time to functional recovery by 2 days in comparison with open surgery. With a power of 80% and alpha of 0.04 to adjust for interim analysis halfway the trial, a total of 250 patients are required to be randomised. Discussion The ORANGE Segments trial is the first multicentre international randomised controlled study to compare short- and long-term surgical and oncological outcomes of laparoscopic and open resections in the posterosuperior segments within an enhanced recovery programme. Trial registration ClinicalTrials.gov NCT03270917. Registered on September 1, 2017. Before start of inclusion. Protocol version: version 12, May 9, 2017

Background No prospective randomized trials comparing transection techniques for the liver parenchyma transection during laparoscopic liver resection have been performed. The aim of the study was to compare the immediate outcomes of hydro-jet dissection with ultrasonic surgical aspirator in laparoscopic liver parenchyma transection in a prospective randomized single-center study. Methods Consecutive patients with liver benign and malignant tumors presenting to a single center from May 2017 to May 2020 were enrolled in the study. The primary endpoint was the intraoperative estimated blood loss. The secondary endpoints included duration of parenchymal transection, morbidity, and overall hospital stay. Results A total of 68 patients were enrolled in the study, with 34 patients in each group. There were no differences between groups in the difficulty of resection (according to IWATE criteria and IMM score) and other basic surgical parameters. No differences were found in all primary and secondary endpoints except the expenditure. The cost of equipment was significantly higher in the group of ultrasonic aspirator. Conclusion Despite the wider use of the ultrasonic aspirator in laparoscopic liver surgery, hydro-jet and ultrasonic surgical aspirators have shown similar efficacy and safety for transection of the liver parenchyma during laparoscopic resection.

Aim. To analyze complications of percutaneous transhepatic cholangiostomy depending on biliary obstruction level and drainage type.Material and methods. Percutaneous transhepatic biliary drainage was carried out in 974 patients with mechanical jaundice of different genesis. External drainage was predominantly performed for distal obstruction, external-internal suprapapillary – for proximal obstruction. Strictures of biliodigestive anastomosis were managed using percutaneous balloon dilatation and long-term external-internal drainage.Results. Overall morbility was 19.1%. Significant relationship between morbidity and obstruction level, drainage type and tubes quantity was detected. Drainage tube dislocation was the most common drainage-related complication both in proximal and distal obstruction. External-internal transpapillary drainage was followed by suppurative cholangitis and acute pancreatitis in 81.5% of cases. External-internal suprapapillary drainage was accompanied by acute cholangitis in 17.1% of patients and was determined by disconnection of subsegmental ducts that required additional drainage tubes placement. In most cases, complications were corrected by minimally invasive surgery and nonsurgical treatment. Overall mortality was 1.3% (0.3% in cases of distal obstruction and 1.8% in cases of proximal obstruction).Conclusion. Percutaneous transhepatic biliary drainage is a routine non-traumatic method of biliary decompression that may be successfully used irrespective to obstruction level and cause of jaundice. External-internal suprapapillary drainage is preferable for proximal biliary obstruction while external-internal transpapillary drainage should be avoided.

Aim. To analyze radiofrequency ablation per se and in combination with other X-ray surgical procedures in patients with liver and bile ducts malignancies. Material and methods. Radiofrequency ablation was used in three groups: percutaneous intervention or in combination with liver resection – group 1 (n = 111); ablation combined with intra-arterial chemoembolization (n = 3) – group 2; RFA followed by right portal vein embolization (RALPPES) in order to induce liver hypertrophy to enable liver resection – group 3 (n = 20). Results. There were no recurrences after radiofrequency ablation. Two-year survival was 55% in patients with hepatocellular carcinoma and liver cirrhosis.Colorectal cancer metastases were followed by 4-year survival near 55%. RFA combined with intra-arterial chemoembolization were associated with complete tumor destruction in patients with hepatocellular carcinoma over 4–5 cm and stabilization in patients with progressive intrahepatic cholangiocarcinoma. Liver hypertrophy was over 50% in two weeks after RALPPES that enables liver resection in 95% of patients. Symptoms of liver failure after hemihepatectomy were not observed in any patients. Conclusion. Combination of interventional methods is able to improve outcomes in patients with liver and bile ducts malignancies.

Aim . To compare early and long-term outcomes of laparoscopic and robot-assisted liver resections with open procedures. Material and Methods. Retrospective case-control study was performed. Pseudo-randomization was used to compare homogeneous data. We have assessed survival in patients with various forms of cholangiocellular carcinoma and colorectal cancer metastases after minimally invasive liver resections. Results. For the period 2013–2017 two hundred and fifteen minimally invasive liver resections were performed including 49 robot-assisted and 166 laparoscopic ones. Malignant tumors were in 45% of cases, benign tumors – in 42%, parasitic neoplasms – in 13%. Early results of minimally invasive resections and 70 comparable open liver resections were compared. All procedures were carried out within the same period at one institution. Immediate results were significantly better after minimally invasive liver resections both before pseudo-randomization and after that. There were 60 pairs of patients after pseudo-randomization. In groups of minimally invasive and open resections blood loss was 396 (0–3400) and 853 (20–6000) ml respectively, time of surgery – 319 (85–580) and 376 (180–775) min, incidence of severe (Clavien–Dindo II and over) complications – 10% (n = 6) and 23% (n = 14), length of postoperative hospital-stay – 9 (3–90) and 12 (2–39) days, respectively. 3-year survival after mini-invasive liver resections for colorectal cancer metastases was 70%, various forms of cholangiocellular carcinoma – 40%. Conclusion. Conventional liver resections can be successfully performed in laparoscopic or robot-assisted fashion in certain patients at specialized center of surgical hepatology with sufficient experience in open and laparoscopic liver surgery.

Introduction The aim of this study was to estimate the immediate and long-term results of laparoscopic and robotic radical surgery for liver alveolar echinococcosis (AE). Methods From 2013 to 2019 6 patients with AE were undergone radically surgery using minimally invasive technologies. In 5 cases, a laparoscopic liver resection was performed, and in one case a Da'Vinci robotic complex was used. The average lesion size was 60 ± 20 mm. Results In three cases (50%) patients with P2 stage of the disease were operated on, in 3 cases with P1. In two cases, in patients with stage P2, a right hemihepatectomy was performed, in 2 cases a segmentectomy 8 with atypical resection segment 4 was performed, in one case a posterior sectionectomy was performed, in one case the intervention was performed with atypical resection of 6 segments. The average age of the patients was 55 years (27-79), three women and three men (1:1). The average size of the lesion was 60 ± 20 cm. The mean operation time and blood loss was 344 ± 141 minutes and 350 ± 333 mL. Complications were observed in one case (16.7%), type II according to Clavien-Dindo, represented by dynamic intestinal obstruction, which developed on the 6th day of the postoperative period and was resolved conservatively. Mean hospital stay was 9 ± 3. Conclusions Laparoscopic and robotic liver resections in the radical treatment of alveococcosis can be safe and feasible in the early stages of alveococcosis (P1-2H0M0), provided they are performed in a specialized hospital with sufficient technical equipment and an experienced surgeon.

Introduction Surgical resection in intrahepatic cholangiocarcinoma (IHCC) is the only feasible modality with a curative ability. The challenge balances between growing the future liver remnant (FLR) in a short time and the same time preventing tumor progression and surgical complications. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) gives a chance for fast kinetic growth, but with high morbidity and mortality. Methods This observation includes 8 comparative patients with IHCC: 4 underwent portal vein embolization (PVE) and 4, ALPPS (3, RALPPS). PVE group has median age 62.2 years, median FLR volume was 564.4 mL, 33%. ALPPS group has median age 58.6 years, median FLR volume was 542.6 mL, 34.9%. One patient had classic ALPPS and 3 had mini-invasive variant. Results The first stage was uncomplicated in the both groups. The median FLR volume became 785 mL (46%) in a 27.5 days and 753.9 mL (38%) in a 17.7 days in PVE and ALPPS groups respectively. Nevertheless, degree of hypertrophy was similar: 41% in PVE and 40.4% in ALPPS. Kinetic growth rate was significantly different: 1.38% and 2.62%/day, respectively. Seven patients completed the second stage. Sever morbidity was revealed with only ALPPS group: grade IIIa (n = 1) and grade V (n = 1) according to Clavien-Dindo. The in-hospital death was associated with classical ALPPS in one patient with extremely small FLR ( Conclusions The modified ALPPS (PRALPPS) may be considered as a safe tool to achieve rapid and sufficient hypertrophy in patients with IHCC.

Introduction The aim of the study was to compare the short- and long-term outcomes of laparoscopic liver resection (LLR) and open liver resection (OLR) for hepatocellular carcinoma (HCC) and to identify patients who might gain more benefits from LLR depending on tumor size. Methods The demographic and peri-operative data, short-term surgical outcomes, and long-term oncological results of 80 patients who received liver resection for HCC between January 2015 and December 2020 were analyzed (LLR, n=56; OLR, n=24). The average size of tumor in both groups were assessed for comparison. Results The average size of tumor was 50 mm in LLR and 80.3 mm in OLR. LLR is associated with less blood loss (p < 0.001), shorter length of hospital stay (p < 0.001), and lower morbidity rate (p = 0.034). The 5-year overall survival (OS) rates in the LLR group were significantly higher than those in the OLR group (81.3% vs. 27.5%; p = 0.020) and 5-year relapse free survival (55.1% vs 31.4%; p = 0.020). The short-term outcomes were better in the LLR group in terms of blood loss, and length of hospital stay, and these benefits attenuated with advancing tumor size. Conclusions LLR for HCC is a safe and feasible procedure that has better short-term and long-term oncological outcomes in patients with tumor size less than 50 mm.

Introduction The diffusion of laparoscopic radical surgery of hydatid liver echinococcosis remains limited. There no published data on a comparative analysis of the immediate and long-term results of radical and conservative laparoscopic surgery for liver hydatid cysts. Comparison of the immediate and long-term outcomes after laparoscopic radical and conservative cystectomies was aimed. Methods HPB center (center 1) and general surgery hospital in endemic area (center 2) participated in retrospective study. Radical surgery included total, subtotal pericystectomy and liver resection. Conservative surgery comprised cystectomy without/with partial pericystectomy. Results The total number of patients was 204. Laparoscopic cystectomy was performed in 97 (47%) patients. Radical (n-40) and conservative (n-61) laparoscopic procedures were performed in center 1 and center 2, respectively. Twenty-five pairs of patients were matched. The length of hospital stay and time of abdominal drainage were significantly shorter after radical surgery before and after PSM. The rate of severe morbidity did not differ. The mean follow-up length was 34 and 45 months in center 1 and center 2, respectively. No differences were found in the disease recurrence rate. Conclusions Laparoscopic radical surgery leads to a reduction in the treatment time and can be recommended as the preferred treatment option in a specialized HPB center.

Importance: Textbook outcome (TO) is a composite measure that captures the most desirable surgical outcomes as a single indicator, yet to date TO has not been defined and assessed in the field of laparoscopic liver resection (LLR) and open liver resection (OLR). Objective: To obtain international agreement on the definition of TO in liver surgery (TOLS) and to assess the incidence of TO in LLR and OLR in a large international multicenter database using a propensity-score matched analysis. Design, Setting, and Participants: Patients undergoing LLR or OLR for all liver diseases between January 2011 and October 2019 were analyzed using a large international multicenter liver surgical database. An international survey was conducted among all members of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) and International Hepato-Pancreato-Biliary Association (IHPBA) to reach agreement on the definition of TOLS. The rate of TOLS was assessed for LLR and OLR before and after propensity-score matching. Factors associated with achieving TOLS were investigated. Main Outcomes and Measures: Textbook outcome, with TOLS defined as the absence of intraoperative incidents of grade 2 or higher, postoperative bile leak grade B or C, severe postoperative complications, readmission within 30 days after discharge, in-hospital mortality, and the presence of R0 resection margin. Results: A total of 8188 patients (4559 LLR; median age, 65 years [interquartile range, 55-73 years]; 2529 were male [55.8%] and 3629 OLR; median age, 64 years [interquartile range, 56-71 years]; 2204 were male [60.7%]) were included in the analysis of whom 69.1% achieved TOLS; 74.8% for LLR and 61.9% for OLR (P 10 cm = OR, 0.550 [95% CI, 0.366-0.826]; P =.004) were associated with a worse TOLS rate. Conclusions and Relevance: In this multicenter study, TOLS was found to be a useful tool for assessing patient-level hospital performance and may have utility in optimizing patient outcomes after LLR and OLR..

Pancreatology Club Professional Medical Community, 1A.S. Loginov Moscow Clinical Research and Practical Center, Moscow Healthcare Department, Moscow; 2A.I. Evdokimov Moscow State University of Medicine and Dentistry, Ministry of Health of Russia, Moscow; 3Kazan State Medical University, Ministry of Health of Russia, Kazan; 4Kazan (Volga) Federal University, Kazan; 5Far Eastern State Medical University, Ministry of Health of Russia, Khabarovsk; 6Morozov City Children's Clinical Hospital, Moscow Healthcare Department, Moscow; 7I.I. Mechnikov North-Western State Medical University, Ministry of Health of Russia, Saint Petersburg; 8Siberian State Medical University, Ministry of Health of Russia, Tomsk; 9M.F. Vladimirsky Moscow Regional Research Clinical Institute, Moscow; 10Maimonides State Classical Academy, Moscow; 11V.I. Razumovsky State Medical University, Ministry of Health of Russia, Saratov; 12I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow; 13S.M. Kirov Military Medical Academy, Ministry of Defense of Russia, Saint Petersburg; 14Surgut State Medical University, Ministry of Health of Russia, Surgut; 15City Clinical Hospital Five, Moscow Healthcare Department, Moscow; 16Nizhny Novgorod Medical Academy, Ministry of Health of Russia, Nizhny Novgorod; 17Territorial Clinical Hospital Two, Ministry of Health of the Krasnodar Territory, Krasnodar; 18Saint Petersburg State Pediatric Medical University, Ministry of Health of Russia, Saint Petersburg; 19Rostov State Medical University, Ministry of Health of Russia, Rostov-on-Don; 20Omsk Medical University, Ministry of Health of Russia, Omsk; 21Russian Medical Academy of Postgraduate Education, Ministry of Health of Russia, Moscow; 22Novosibirsk State Medical University, Ministry of Health of Russia, Novosibirsk; 23Stavropol State Medical University, Ministry of Health of Russia, Stavropol; 24Kemerovo State Medical University, Ministry of Health of Russia, Kemerovo; 25N.I. Pirogov Russian National Research Medical University, Ministry of Health of Russia, Moscow; 26A.M. Nikiforov All-Russian Center of Emergency and Radiation Medicine, Russian Ministry for Civil Defense, Emergencies and Elimination of Consequences of Natural Disasters, Saint Petersburg; 27Research Institute for Medical Problems of the North, Siberian Branch, Russian Academy of Sciences, Krasnoyarsk; 28S.P. Botkin City Clinical Hospital, Moscow Healthcare Department, Moscow; 29Tver State Medical University, Ministry of Health of Russia, Tver The Russian consensus on the diagnosis and treatment of chronic pancreatitis has been prepared on the initiative of the Russian Pancreatology Club to clarify and consolidate the opinions of Russian specialists (gastroenterologists, surgeons, and pediatricians) on the most significant problems of diagnosis and treatment of chronic pancreatitis. This article continues a series of publications explaining the most significant interdisciplinary consensus statements and deals with enzyme replacement therapy.Российский консенсус по диагностике и лечению хронического панкреатита подготовлен по инициативе Российского 'Панкреатологического клуба' с целью выяснения и консолидации мнений отечественных специалистов (гастроэнтерологов, хирургов и педиатров) по наиболее важным проблемам диагностики и лечения хронического панкреатита. Настоящая статья продолжает серию публикаций, разъясняющих наиболее важные положения междисциплинарного консенсуса и посвящена вопросам заместительной ферментной терапии.

Aim: to assess the role of hepatobiliary scintigraphy for prognosis of hepatic failure after liver resection; to determine threshold index of hepatic uptake of radioactive agent as an indication for surgical prevention of hepatic failure. Material and Methods. The study included 2 groups of patients who underwent hepatobiliary scintigraphy. The 1st group consisted of 50 patients with diffuse liver diseases (chronic hepatitis, liver cirrhosis) in whom histological examination of liver was performed according to METAVIR. 49 patients with liver tumors underwent advanced liver resections (over segments by Couinaud). Results. The highest median of hepatic uptake (2,86) was revealed in patients with liver fibrosis F1, the lowest (2,02) – in patients with liver fibrosis F4. Threshold value of hepatic uptake was 2,4. In 18 patients with hepatic uptake index

To assess an experience of robot-assisted liver resection using CUSUM-test.The results of 46 robot-assisted liver resections were retrospectively analyzed by using of CUSUM-test.There were 3 periods in development of the technology. The 1В последнее десятилетие набирает популярность оценка кривых обучения при помощи метода статистического анализа CUSUM (cumulative sum). Цель исследования - оценить опыт освоения робот-ассистированных резекций печени при помощи метода CUSUM. Материал и методы. При помощи метода CUSUM проведен ретроспективный анализ результатов 46 робот-ассистированных резекций печени. Результаты. Выделены 3 периода в освоении технологии: 1-й - обучение операциям с низким индексом сложности (n=16), 2-й - расширение показаний к операциям с высоким уровнем сложности (n=18) и 3-й - стабилизация показателей (n=12). Изучена динамика индекса сложности резекций печени, объема интраоперационной кровопотери, длительности операции и частоты осложнений II-V класса по Clavien-Dindo. Согласно данным анализа, снижение показателей кровопотери и длительности резекции печени произошло после 5-й операции. Переход к сложным резекциям печени потребовал выполнения 16 операций. Стабилизация периоперационных параметров наступила после 34 резекций печени. Заключение. Технология CUSUM представляется эффективным методом оценки кривой обучения робот-ассистированным резекциям печени.