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Objectives: The introduction of lumen-apposing metal stents (LAMSs) has revolutionized the field of therapeutic endoscopic ultrasound. This study aims to evaluate the efficacy and safety of LAMS in creating an endoscopic ultrasound-guided anastomosis between two segments of the gastrointestinal (GI) tract., Methods: Data from all consecutive LAMS procedures for anastomosis creation between two segments of the GI, conducted between October 2019 and February 2024, were retrospectively analyzed for technical success (defined as correct deployment of the LAMS in the target), clinical success (defined as achievement of the intended clinical goal), and adverse events., Results: A total of 145 LAMS procedures were performed in 136 patients. Indications for LAMS procedures included the need for endoscopic access to or reversal of surgically excluded segments of the GI tract ( n = 73, 50.3%), and the alleviation of any GI outflow obstruction ( n = 72, 49.7%). The overall technical and clinical success rates were very high (97.2% and 95.2%, respectively). Adverse events were observed in 20/145 (13.8%) cases, including 11 (7.6%) minor events (AGREE <3) and nine (6.2%) major events (AGREE ≥3). Major events included stent migration ( n = 1), persisting fistula ( n = 3), and bleeding ( n = 4). All adverse events were successfully managed, and there were no procedure-related deaths. Loss of LAMS patency occurred in 4/145 (2.8%) cases and could be endoscopically managed in all cases., Conclusions: The creation of anastomoses with LAMS between two segments of the GI tract appears to be effective and safe, with a low reintervention rate due to loss of LAMS patency., Competing Interests: Pieter Hindryckx has received speaker and/or consultancy fees from Boston Scientific, Taewoong Medical, Duomed, and Viatris. Lindsey Devisscher, Niki Rashidian, Enrico Palmeri, and Emine Gökce declare no conflict of interest., (© 2024 The Author(s). DEN Open published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.)

Background: Cytoreductive surgery (CRS) is a widely acknowledged treatment approach for peritoneal metastasis, showing favorable prognosis and long-term survival. Intraoperative scoring systems quantify tumoral burden before CRS and may predict complete cytoreduction (CC). This study reviews the intraoperative scoring systems for predicting CC and optimal cytoreduction (OC) and evaluates the predictive performance of the Peritoneal Cancer Index (PCI) and Predictive Index Value (PIV)., Methods: Systematic searches were conducted in Embase, MEDLINE, and Web of Science. Meta-analyses of extracted data were performed to compare the absolute predictive performances of PCI and PIV., Results: Thirty-eight studies (5834 patients) focusing on gynecological (n = 34; 89.5%), gastrointestinal (n = 2; 5.3%) malignancies, and on tumors of various origins (n = 2; 5.3%) were identified. Seventy-seven models assessing the predictive performance of scoring systems (54 for CC and 23 for OC) were identified with PCI (n = 39/77) and PIV (n = 16/77) being the most common. Twenty models (26.0%) reinterpreted previous scoring systems of which ten (13%) used a modified version of PIV (reclassification). Meta-analyses of models predicting CC based on PCI (n = 21) and PIV (n = 8) provided an AUC estimate of 0.83 (95% confidence interval [CI] 0.79-0.86; Q = 119.6, p = 0.0001; I 2  = 74.1%) and 0.74 (95% CI 0.68-0.81; Q = 7.2, p = 0.41; I 2  = 11.0%), respectively., Conclusions: Peritoneal Cancer Index models demonstrate an excellent estimate of CC, while PIV shows an acceptable performance. There is a need for high-quality studies to address management differences, establish standardized cutoff values, and focus on non-gynecological malignancies., (© 2024. Society of Surgical Oncology.)

Introduction: Pancreatic neuroendocrine tumors (PNETs) are typically diagnosed using endoscopic ultrasound-guided (EUS) biopsy, which can be associated with complications. Since 2016, DOTATATE PET/CT has emerged as an effective tool to localize and stage PNETs., Methods: Patients with PNETs who underwent R0 resections were identified from the 2004-2019 National Cancer Database PUF. Joinpoint regression and multivariable logistic regression were used to analyze trends in the use of biopsy., Results: Of 16,746 R0 resected PNET patients, 44 ​% underwent diagnostic biopsy. Joinpoint regression showed a significant increase in the use of biopsy from 2004 to 2019 (APC 1.80, p ​< ​0.001). A higher percentage of patients diagnosed after DOTATATE approval underwent biopsy compared to those diagnosed before (48 ​% vs. 42 ​%, p ​< ​0.001). Adjusted analysis showed diagnosis after 2016 was associated with increased odds of biopsy (OR ​= ​1.67, p ​< ​0.001)., Conclusions: Despite technologic advancement with DOTATATE PET/CT, there has been a significant increase in the proportion of resectable PNETs undergoing preoperative biopsy., Competing Interests: Declaration of competing interest The authors report no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is a procedure for minimally invasive drug administration in patients with peritoneal metastasis. Previous studies have emphasized the importance of uniformity in treatment protocols and standardization of this practice. This study aimed to reach a consensus on eligibility, patient selection, and choice of chemotherapy for PIPAC., Methods: A three-round modified Delphi study was conducted. A steering group formulated a list of baseline statements, addressing the objectives. The steering group consisted of seven expert surgical and medical oncologists. Available evidence and published key opinions were critically reviewed. An international expert panel scored those statements on a 4-point Likert scale. The statements were submitted electronically and anonymously. Consensus was reached if the agreement rate was ≥75%. A minimum Cronbach's alpha of >0.8 was set., Results: Forty-five (45/58; 77.6%) experts participated and completed all rounds. Experts were digestive surgeons (n = 28), surgical oncologists (n = 7), gynecologists (n = 5), medical oncologists (n = 4), and one clinical researcher. Their assessment of 81 preliminary statements in the first round resulted in 41 consolidated statements. In round two, consensus was reached on 40 statements (40/41; 97.6%) with a consensus of ≥80% for each individual statement. In the third round, 40 statements were unanimously approved as definitive. The choice of first- and second-line chemotherapy remained controversial and could not reach consensus., Conclusions: This International Delphi study provides practical guidance on eligibility and patient selection for PIPAC. Ongoing trial data and long-term results that could contribute to the further standardization of PIPAC are eagerly awaited., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (© 2024 Elsevier Ltd, BASO ∼ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: Machine learning (ML) approaches have become increasingly popular in predicting surgical outcomes. However, it is unknown whether they are superior to traditional statistical methods such as logistic regression (LR). This study aimed to perform a systematic review and meta-analysis to compare the performance of ML vs LR models in predicting postoperative outcomes for patients undergoing gastrointestinal (GI) surgery., Methods: A systematic search of Embase, MEDLINE, Cochrane, Web of Science, and Google Scholar was performed through December 2022. The primary outcome was the discriminatory performance of ML vs LR models as measured by the area under the receiver operating characteristic curve (AUC). A meta-analysis was then performed using a random effects model., Results: A total of 62 LR models and 143 ML models were included across 38 studies. On average, the best-performing ML models had a significantly higher AUC than the LR models (ΔAUC, 0.07; 95% CI, 0.04-0.09; P < .001). Similarly, on average, the best-performing ML models had a significantly higher logit (AUC) than the LR models (Δlogit [AUC], 0.41; 95% CI, 0.23-0.58; P < .001). Approximately half of studies (44%) were found to have a low risk of bias. Upon a subset analysis of only low-risk studies, the difference in logit (AUC) remained significant (ML vs LR, Δlogit [AUC], 0.40; 95% CI, 0.14-0.66; P = .009)., Conclusion: We found a significant improvement in discriminatory ability when using ML over LR algorithms in predicting postoperative outcomes for patients undergoing GI surgery. Subsequent efforts should establish standardized protocols for both developing and reporting studies using ML models and explore the practical implementation of these models., Competing Interests: Declaration of competing interest The authors declare no competing interests., (Copyright © 2024 Society for Surgery of the Alimentary Tract. All rights reserved.)

Objective: To develop and update evidence-based and consensus-based guidelines on laparoscopic and robotic pancreatic surgery., Summary Background Data: Minimally invasive pancreatic surgery (MIPS), including laparoscopic and robotic surgery, is complex and technically demanding. Minimizing the risk for patients requires stringent, evidence-based guidelines. Since the International Miami Guidelines on MIPS in 2019, new developments and key publications have been reported, necessitating an update., Methods: Evidence-based guidelines on 22 topics in 8 domains were proposed: terminology, indications, patients, procedures, surgical techniques and instrumentation, assessment tools, implementation and training, and artificial intelligence. The Brescia Internationally Validated European Guidelines on Minimally Invasive Pancreatic Surgery (EGUMIPS, September 2022) used the Scottish Intercollegiate Guidelines Network (SIGN) methodology to assess the evidence and develop guideline recommendations, the Delphi method to establish consensus on the recommendations among the Expert Committee, and the AGREE II-GRS tool for guideline quality assessment and external validation by a Validation Committee., Results: Overall, 27 European experts, 6 international experts, 22 international Validation Committee members, 11 Jury Committee members, 18 Research Committee members, and 121 registered attendees of the 2-day meeting were involved in the development and validation of the guidelines. In total, 98 recommendations were developed, including 33 on laparoscopic, 34 on robotic, and 31 on general MIPS, covering 22 topics in 8 domains. Out of 98 recommendations, 97 reached at least 80% consensus among the experts and congress attendees, and all recommendations were externally validated by the Validation Committee., Conclusions: The EGUMIPS evidence-based guidelines on laparoscopic and robotic MIPS can be applied in current clinical practice to provide guidance to patients, surgeons, policy-makers, and medical societies., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: The study aim was to develop and validate models to predict clinically significant posthepatectomy liver failure (PHLF) and serious complications [a Comprehensive Complication Index (CCI)>40] using preoperative and intraoperative variables., Background: PHLF is a serious complication after major hepatectomy but does not comprehensively capture a patient's postoperative course. Adding the CCI as an additional metric can account for complications unrelated to liver function., Methods: The cohort included adult patients who underwent major hepatectomies at 12 international centers (2010-2020). After splitting the data into training and validation sets (70:30), models for PHLF and a CCI>40 were fit using logistic regression with a lasso penalty on the training cohort. The models were then evaluated on the validation data set., Results: Among 2192 patients, 185 (8.4%) had clinically significant PHLF and 160 (7.3%) had a CCI>40. The PHLF model had an area under the curve (AUC) of 0.80, calibration slope of 0.95, and calibration-in-the-large of -0.09, while the CCI model had an AUC of 0.76, calibration slope of 0.88, and calibration-in-the-large of 0.02. When the models were provided only preoperative variables to predict PHLF and a CCI>40, this resulted in similar AUCs of 0.78 and 0.71, respectively. Both models were used to build 2 risk calculators with the option to include or exclude intraoperative variables ( PHLF Risk Calculator; CCI>40 Risk Calculator )., Conclusions: Using an international cohort of major hepatectomy patients, we used preoperative and intraoperative variables to develop and internally validate multivariable models to predict clinically significant PHLF and a CCI>40 with good discrimination and calibration., Competing Interests: N.R. obtained a grant for postdoctoral fundamental research from the Fund for Scientific Research (FWO)—Flanders Belgium (grant file number: 1260123N). J.W. was supported by the UCSF Noyce Initiative for Digital Transformation in Computational Biology & Health, Computational Innovator Postdoctoral Fellowship Award. The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The treatment of borderline resectable (BR) and locally advanced (LA) pancreatic ductal adenocarcinoma (PDAC) has evolved with a wider application of neoadjuvant chemotherapy (NACHT). The aim of this study was to identify predictive factors for survival in BR and LA PDAC., Methods: Clinicopathologic data of patients with BR and LA PDAC who underwent surgical exploration between January 2011 and June 2021 were retrospectively collected. Survival from the date of surgery was estimated using the Kaplan-Meier method. Simple and multiple Cox proportional hazards models were fitted to identify factors associated with survival. Surgical resection was analyzed in combination with the involvement of lymph nodes as this last was only known after a formal resection., Results: Ninety patients were surgically explored (BR: 45, LA: 45), of which 51 (57%) were resected (BR: 31, LA: 20). NACHT was administered to 43 patients with FOLFIRINOX being the most frequent regimen applied (33/43, 77%). Major complications (Clavien-Dindo grade III and IV) occurred in 7.8% of patients and 90-day mortality rate was 3.3%. The median overall survival since surgery was 16 months (95% CI 12-20) in the group which underwent surgical resection and 10 months (95% CI 7-13) in the group with an unresectable tumor (p=0.001). Cox proportional hazards models showed significantly lower mortality hazard for surgical resection compared to no surgical resection, even after adjusting for National Comprehensive Cancer Network  (NCCN) classification and administration of NACHT [surgical resection with involved lymph nodes vs no surgical resection (cHR 0.49; 95% CI 0.29-0.82; p=0.007)]. There was no significant difference in survival between patients with BR and LA disease (cHR= 1.01; 95% CI 0.63-1.62; p=0.98)., Conclusions: Surgical resection is the only predictor of survival in patients with BR and LA PDAC, regardless of their initial classification as BR or LA. Our results suggest that surgery should not be denied to patients with LA PDAC a priori. Prospective studies including patients from the moment of diagnosis are required to identify biologic and molecular markers which may allow a better selection of patients who will benefit from surgery., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: 3D rendering (3DR) represents a promising approach to plan surgical strategies. The study aimed to compare the results of minimally invasive liver resections (MILS) in patients with 3DR versus conventional 2D CT-scan., Methods: We performed 118 3DR for various indications; the patients underwent a preoperative tri-phasic CT-scan and rendered with Synapse3D® Software. Fifty-six patients undergoing MILS with pre-operative 3DR were compared to a similar cohort of 127 patients undergoing conventional pre-operative 2D CT-scan using the propensity score matching (PSM) analysis., Results: The 3DR mandated pre-operative surgical plan variations in 33.9% cases, contraindicated surgery in 12.7%, providing a new surgical indication in 5.9% previously excluded cases. PSM identified 39 patients in both groups with comparable results in terms of conversion rates, blood loss, blood transfusions, parenchymal R1-margins, grade ≥3 Clavien-Dindo complications, 90-days mortality, and hospital stay respectively in 3DR and conventional 2D. Operative time was significantly increased in the 3DR group (402 vs. 347 min, p = 0.020). Vascular R1 resections were 25.6% vs 7.7% (p = 0.068), while the conversion rate was 0% vs 10.2% (p = 0.058), respectively, for 3DR group vs conventional 2D., Conclusion: 3DR may help in surgical planning increasing resectability rate while reducing conversion rates, allowing the precise identification of anatomical landmarks in minimally invasive parenchyma-preserving liver resections., Competing Interests: Conflict of interest None to declare., (Copyright © 2023 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Objective: To compare different criteria for post-hepatectomy liver failure (PHLF) and evaluate the association between International Study Group of Liver Surgery (ISGLS) PHLF and the Comprehensive Complication Index (CCI)" and 90-day mortality., Summary of Background Data: PHLF is a serious complication following hepatic resection. Multiple criteria have been developed to characterize PHLF., Methods: Adults who underwent major hepatectomies at twelve international centers (2010-2020) were included. We identified patients who met criteria for PHLF based on three definitions: 1) ISGLS, 2) Balzan (INR > 1.7 and bilirubin > 2.92mg/dL) or 3) Mullen (peak bilirubin >7mg/dL). We compared the 90-day mortality and major morbidity predicted by each definition. We then used logistic regression to determine the odds of CCI>40 and 90-day mortality associated with ISGLS grades., Results: Among 1646 included patients, 19 (1.1%) met Balzan, 68 (4.1%) met Mullen, and 444 (27.0%) met ISGLS criteria for PHLF. Of the three definitions, the ISGLS criteria best predicted 90-day mortality (AUC = 0.72; sensitivity 69.4%). Patients with ISGLS grades B&C were at increased odds of CCI > 40 (grade B OR 4.0; 95% CI: 2.2-7.2; grade C OR 137.0; 95% CI: 59.2-317.4). Patients with ISGLS grade C were at increased odds of 90-day mortality (OR 113.6; 95% CI: 55.6-232.1). Grade A was not associated with CCI> 40 or 90-day mortality., Conclusions: In this diverse international cohort of major hepatectomies, ISGLS grade A was not associated with 90-day mortality or high CCI, calling into question the current classification of patients in this group as having clinically significant PHLF., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The Lancet Commission on Global Surgery has identified workforce development as an important component of National Surgical Plans to advance the treatment of surgical disease in low- and middle-income countries. The goal of our study is to identify priorities of surgeon educators in the region so that collaboration and intervention may be appropriately targeted., Study Design: The American College of Surgeons Operation Giving Back, in collaboration with leaders of the College of Surgeons of Eastern, Central and Southern Africa (COSECSA), developed a survey to assess the needs and limitations of surgical educators working under their organizational purview. COSECSA members were invited to complete an online survey to identify and prioritize factors within 5 domains: (1) Curriculum Development, (2) Faculty Development, (3) Structured Educational Content, (4) Skills and Simulation Training, and (5) Trainee Assessment and Feedback., Results: One-hundred sixty-six responses were received after 3 calls for participation, representing all countries in which COSECSA operates. The majority of respondents (78%) work in tertiary referral centers. Areas of greatest perceived need were identified in the Faculty Development and Skills and Simulation domains. Although responses differed between domains, clinical responsibilities, cost, and technical support were commonly cited as barriers to development., Conclusions: This needs assessment identified educational needs and priorities of COSECSA surgeons. Our study will serve as a foundation for interventions aimed at further improving graduate surgical education and ultimately patient care in the region., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Virtual reality (VR) is increasingly used in surgical education, but evidence of its benefits in complex cognitive training compared to conventional 3-dimensional (3D) visualization methods is lacking. The objective of this study is to assess the impact of 3D liver models rendered visible by VR or desktop interfaces (DIs) on residents' performance in clinical decision-making., Method: From September 2020 to April 2021, a single-blinded, crossover randomized educational intervention trial was conducted at two university hospitals in Belgium and Italy. A proficiency-based stepwise curriculum for preoperative liver surgery planning was developed for general surgery residents. After completing the training, residents were randomized in one of two assessment sequences to evaluate ten real clinical scenarios., Results: Among the 50 participants, 46 (23 juniors/23 seniors) completed the training and were randomized. Forty residents (86.96%) achieved proficiency in decision-making. The accuracy of virtual surgical planning using VR was higher than that using DI in both groups A (8.43 ± 1.03 vs 6.86 ± 1.79, p < 0.001) and B (8.08 ± 0.9 vs 6.52 ± 1.37, p < 0.001)., Conclusion: Proficiency-based curricular training for liver surgery planning successfully resulted in the acquisition of complex cognitive skills. VR was superior to DI visualization of 3D models in decision-making., Gov Id: NCT04959630., (Copyright © 2022 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Objective: To identify, categorize, and evaluate the quality of literature, and to provide evidence-based guidelines on virtual surgical education within the cognitive and curricula, psychomotor, and faculty development and mentorship domains., Summary of Background Data: During the coronavirus disease 2019 pandemic, utilizing virtual learning modalities is expanding rapidly. Although the innovative methods must be considered to bridge the surgical education gap, a framework is needed to avoid expansion of virtual education without proper supporting evidence in some areas., Methods: The Association for Surgical Education formed an ad-hoc research group to evaluate the quality and methodology of the current literature on virtual education and to build evidence-based guidelines by utilizing the SiGN methodology. We identified patient/problem-intervention-comparison-outcome-style questions, conducted systematic literature reviews using PubMed, EMBASE, and Education Resources information Center databases. Then we formulated evidence-based recommendations, assessed the quality of evidence using Grading of Recommendations, Assessment, Development, and Evaluation, Newcastle-Ottawa Scale for Education, and Kirkpatrick ratings, and conducted Delphi consensus to validate the recommendations., Results: Eleven patient/problem-intervention-comparison-outcome-style questions were designed by the expert committees. After screening 4723 articles by the review committee, 241 articles met inclusion criteria for full article reviews, and 166 studies were included and categorized into 3 domains: cognition and curricula (n = 92), psychomotor, (n = 119), and faculty development and mentorship (n = 119). Sixteen evidence-based recommendations were formulated and validated by an external expert panel., Conclusion: The evidence-based guidelines developed using SiGN methodology, provide a set of recommendations for surgical training societies, training programs, and educators on utilizing virtual surgical education and highlights the area of needs for further investigation., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Hepatopancreatobiliary (HPB) Fellowship training in the Americas consists of 3 distinctive routes with variable curricula: Surgical Oncology Fellowship via the Society of Surgical Oncology (SSO), Abdominal Transplant Surgery Fellowship via the American Society of Transplant Surgeons (ASTS), and HPB Fellowship via the Americas Hepato-Pancreato-Biliary Association (AHPBA). Our objective was to establish a pan-American consensus among HPB surgeons, surgical oncologists, abdominal transplant surgeons, and general surgery residency program directors (GSPDs) on a core knowledge curriculum for HPB fellowship, and to identify topics appropriate for general surgery residency and subspecialty beyond HPB fellowship., Study Design: A 3-round modified Delphi process was used. Baseline statements were developed by the Education and Training Committee of the AHPBA, in collaboration with representatives of the SSO, ASTS, and GSPDs. The expert panel, consisting of members of the 3 societies together with GSPDs, rated the statements on a 5-point Likert scale and suggested editing or adding new statements. A statement was included in the final curriculum when Cronbach's alpha value was ≥ 0.8 and ≥ 80% of the panel agreed on inclusion., Results: The response rate was 100% for the first round, and 98% for the second and third rounds. Eighty-nine of 138 proposed statements were included in the final HPB fellowship curriculum. Curricula for general surgery residency and subspecialty beyond HPB fellowship included 50 and 29 statements, respectively., Conclusions: A multinational consensus on core knowledge for an HPB fellowship curriculum was achieved via the modified Delphi method. This core curriculum may be used to standardize HPB fellowship training across different pathways in the Americas., (Copyright © 2021 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: In general surgery residency, hepatobiliary training varies significantly across the world. The aim of this study was to establish an international consensus among hepatobiliary surgeons on components of a hepatobiliary curriculum for general surgery residents., Methods: A three-round modified Delphi technique was employed. Fifty-two hepatobiliary surgeons involved in general surgery training programs were invited. An initial questionnaire was developed by a group of experts in hepatobiliary and educational research after a systematic literature review. It comprised 90 statements about knowledge, technical skills, attitudes, and postoperative care. Panelists could add or alter items. The survey was delivered electronically and the panel was instructed to score the items based on 5-point Likert scale. Consensus was reached when at least 80% of panelists agreed on a statement with Cronbach's alpha value >0.8., Results: Forty-one (79%) experts have participated. Sixteen panelists are based in Asia, 14 in Europe, and 11 in the Americas. Eighty percent of all proposed skills (81/101) were considered fundamental including knowledge (39/43), technical skills (16/32), attitude (15/15), and postoperative care (11/11)., Conclusion: An international consensus was achieved on components of a hepatobiliary curriculum. Acquiring broad knowledge is fundamental during residency. Advanced liver resection techniques require specialized hepatobiliary training., (Copyright © 2020 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

The objective of the study was to identify and to evaluate the impact of educational interventions to learn and train liver surgery outside the operating room. A systematic literature search was conducted using PubMed, Web of Science, Embase, and ERIC databases from inception to September 2019 according to the PRISMA guidelines. Studies describing and assessing outcomes of educational interventions in liver surgery, outside the operating room, were included. Neither language nor date of publication restriction was applied. Methodological quality was appraised using NOS-E (Newcastle-Ottawa Scale for Education), and the level of evidence was evaluated based on GRADE (Grades of Recommendation Assessment, Development, and Evaluation) standards. Of the 10,403 screened abstracts, 53 articles were eligible for inclusion, comprising 27 descriptive studies (50.9%), 14 case series assessing any relevant outcome (26.4%), 8 non-randomized controlled trials (15.1%), and 4 randomized controlled studies (7.5%). Almost half (26/53) of the studies did not include any participants, while the remainder of the publications (27/53) involved 1306 learners. The majority of the studies focused on cognitive knowledge (31/53) and/or psychomotor skills training (24/53). Only one publication assessed affective skills. The GRADE score was very low or low in most articles (46/53). Five studies were scored high (5-6) according to NOS-E. Two studies reported data regarding the reliability and validity of employed assessment tools. High-quality studies, particularly well-designed randomized controlled trials that evaluate the effectiveness of simulation-based training on learner behavior and patient outcomes in liver surgery, are still lacking. Forthcoming studies should use robust assessment tools supported by validity evidence.

The liver is a common site of metastatic cancer spread, and metastatic lesions are the most common malignant liver tumors. Diagnosis of liver metastases often is established based on clinical assessment, laboratory tests, and appropriate imaging. Surgical resection is the treatment of choice for resectable colorectal and neuroendocrine liver metastases. Long-term survival outcome data after treatment of hepatic metastases of noncolorectal non-neuroendocrine tumors are less robust. The treatment strategy for patients with liver metastases should be determined case by case in a multidisciplinary setting., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: The purpose of this study was to evaluate the feedback of participants upon laparoscopic liver surgery (LLS) course on Thiel-embalmed human bodies., Methods: From 2010 to 2017, ten LLS masterclasses have been organized by the Department of Hepatobiliary Surgery at Ghent University Hospital. A 23-question anonymous survey was electronically sent to 119 participants between November 2017 and January 2018, exploring their characteristics and asking for evaluation of the course. The obstacles for implementing LLS in their centers have been assessed., Results: Sixty-four surgeons (53.8%) responded to the survey; 42 (65.6%) were employed at a university hospital; and 39 (60.9%) were in the first decade of their practice as a consultant surgeon. Forty-three (67.2%) surgeons reported an increased percentage of LLS cases afterward. Training on Thiel cadavers was considered superior (49.2%) to other training options including proctoring in the operating room (34.9%), virtual reality (6.3%), video training (4.8%) and practicing on pigs (4.8%). Obstacles identified contained inadequate training, patient's referral pattern, financial issues, lack of dedicated surgical team and time constrains., Conclusions: This survey revealed that a structured short-time program incorporating interactive discussion, live operations and hands-on training on human bodies under proctorship may enhance efficient training in laparoscopic liver surgery. In a step forward for upcoming courses, the importance of team building has to be addressed.

The 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) is the most toxic polychlorinated dibenzo-p-dioxin. The OH-initiated oxidation of TCDD has been studied using the density functional, canonical transition state, and canonical Rice-Ramsperger-Kassel-Marcus theories. The kinetic data were corrected for quantum tunneling by the Wigner and Eckart models. All OH addition and hydrogen atom abstraction channels were thermodynamically exergonic. The kinetic and thermodynamic data analysis at the reliable level MPWB1K/MG3S//M06-2X/MG3S indicate that the addition of OH to the carbon atom adjacent to the oxygen atom in dioxin ring leads to the formation of predominant adduct. The calculated bimolecular rate constant for the formation of predominant adduct was ~5.97-6.75 × 10 -13  cm 3  molecule -1  s -1 , its branching ratio was ~0.955, and the overall rate constant for the OH-initiated oxidation of TCDD was ~6.25-7.08 × 10 -13  cm 3  molecule -1  s -1 . The atmospheric lifetime of TCDD determined by OH was ~8.17-9.26 days indicating the TCDD can be categorized as medium lifetime organic pollutant., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: To evaluate the European experience after Adult-to-adult living donor liver transplantation using the left liver (LL-aLDLT)., Summary Background Data: LL-aLDLT decreases donor risk but provides a smaller graft that increases recipient risk as compared with right liver (RL-aLDLT). However, there is little knowledge of results obtained after LL-aLDLT in Europe., Methods: This is a European multicenter retrospective study which aims to analyze donor and recipient outcomes after 46 LL-aLDLT., Results: Seventy-six percent of the grafts were harvested by minimally invasive approach. Mean donor hospital stay was 7.5 ± 3.5 days. Donor liver function was minimally impaired, with 36 donors (78.3%) without any 90-day complication, and 4 (8.7%) presenting major complications. One, 3, and 5-year recipient survival was 90.9%, 82.7%, and 82.7%, respectively. However, graft survival was of 59.4%, 56.9%, and 56.9% at 1, 3, and 5 years respectively, due to a 26.1% urgent liver retransplantation (ReLT) rate, mainly due to SFSS (n = 5) and hepatic artery thrombosis (HAT, n = 5). Risk factor analysis for ReLT and HAT showed an association with a graft to body weight ratio (GBWR) <0.6% (P = 0.01 and P = 0.024, respectively) while SFSS was associated with a recipient MELD ≥14 (P = 0.019). A combination of donor age <45 years, MELD <14 and actual GBWR >0.6% was associated with a lower ReLT rate (0% vs. 33%, P = 0.044)., Conclusions: Our analysis showed low donor morbidity and preserved liver function. Recipient outcomes, however, were hampered by a high ReLT rate. A strict selection of both donor and recipients is the key to minimize graft loss.

Colorectal lymphoma is an extremely rare disease, representing less than 0.5% of all primary colorectal neoplasms. The disease is usually diagnosed in the advanced stages because of its primary non-specific symptoms. The most common involved site is cecum followed by rectum and ascending colon. Diffuse large B-cell lymphoma is a more frequent subtype. Although surgical resection is often technically feasible, optimal therapy for a colorectal lymphoma, especially rectal lymphoma, has not yet been identified. The authors describe a patient with the primary rectal lymphoma, high-grade features and complete response to chemotherapy.

Bowel stent insertion has a variety of complications one major of which is colonic perforation. The purpose of this article is to reveal two cases with delayed colonic perforation after stent placement to relieve bowel obstruction caused by rectal cancer. The first patient was a 55 year-old man who was a candidate for stent placement to avoid palliative surgery and relieve his bowel obstruction. Although the procedure resulted in complete relief of patient symptoms, but he returned with signs of peritonitis 10 days after the stent placement. A perforation was found at rectosigmoid junction on laparotomy. The second patient was a 60 year-old man who underwent a successful stent placement and returned 3 months later with a complaint of abdominal pain that showed up to be due to a rectal perforation on investigations. In conclusion, bowel perforation following stent placement can be a major complication, so close follow-up is necessary to detect it as soon as possible and prevent it from becoming an irreparable complication.

Background: In the modern day cities, home treadmill usage is increasing. Toddlers are prone to a special injury by the treadmill, during workout the toddler tries to get on the belt and the roller action pulls the fingers under the belt and get caught between the belt and a metal rod under the machine and the belt scrapes the fingers. If untreated some of these injuries will lead to flexion contracture. The usual treatment is release of contracture and skin grafting, however, graft discoloration and recurrence of contracture are the complications of this method and the patients usually seek treatment for the brown discoloration of the grafts at a later age., Objectives: In this study we assess the results of Z-plasty in combination with soft tissue distraction without skin grafting with long term usage of splint as an alternative treatment for these patients., Materials and Methods: In this retrograde descriptive cross-sectional study, we evaluated the patients presented with treadmill hand injuries between the years 2006 and 2011. Demographic data including age and sex in addition to other information including location of trauma, severity of trauma, time elapsed between the trauma and treatment, type of treatment including wound care and surgical method and treatment outcomes were assessed., Results: A total of 8 patients (3 girls and 5 boys) following finger treadmill injury were assessed. 15 fingers in 7 patients had volar injury. The middle finger was the most commonly injured finger. In all patients a minimum of 2 fingers were injured and in just 1 patient 3 fingers were injured. In long-term follow-up all the patients had acceptable volar skin and complete ROM of the fingers., Conclusions: Due to discoloration of the skin graft and recurrence of contracture following skin graft as the sole treatment for the injury, application of Z-plasty with soft tissue distraction and long term splints seems to be a proper alternative treatment for these patients.