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Background: Fellowships in HPB surgery are lacking across Europe. The aim of this survey was to investigate preferences towards an HPB-fellowship structure among trainees and trainers.

Methods: A cross-sectional pan-European survey of trainees and consultants in HPB across Europe. Preferred content, duration and construct of a fellowship program was explored.

Results: Responses from 221 eligible participants were analysed, covering all European regions (40 % trainees, of which 31 % women). Preferred duration was 2 years (53 %), international availability (71 %) and in English language (by two-thirds overall; 74 % among trainees). A majority About two-thirds (63 %) preferred an official fellowship teaching curriculum provided by the E-AHPBA. Most The vast majority of participants (n = 211; 95 %) supported accreditation of HPB-fellowships by the E-AHPBA. Trainees reported higher priorities towards technical training (i.e. time in operating room; first surgeon opportunity; minimal-invasive technique training) than consultants, while time for non-operative activities (i.e. ward rounds; responsibility for multidisciplinary team meetings etc) was valued higher by consultants.

Conclusions: We identified preferences and needs towards construct and competence in HPB fellowships with strong support for involvement of E-AHPBA in providing a involvement teaching curriculum and accreditation. A unified HPB fellowship construct and registry across Europe guided by E-AHPBA may take this into consideration.

Background: Perihilar cholangiocarcinoma (PHC) often requires major hepatectomy with extrahepatic bile duct resection, carrying the risk of post-hepatectomy liver failure (PHLF). Central hepatectomy (CH), an alternative technique, aims to preserve functional liver reserve. This study evaluated the feasibility of CH and outcomes for patients with PHC within the paradigm of parenchymal-sparing hepatectomy.

Methods: A retrospective analysis included PHC patients who underwent CH between March 2019 and January 2023. Preoperative evaluations involved multimodality imaging and assessment of future remnant liver volume.

Results: Fourteen patients underwent CH for PHC. Tumor locations were perihilar bile duct (10 patients), and entire extrahepatic bile duct involvement (four patients). Median operative time and intraoperative blood loss were 679.5 min and 450 mL, respectively. Clinically-relevant PHLF occurred in two patients, with one sepsis-related death. Nine patients achieved R0 resection. Functional liver reserve parameters exceeded the standard procedure (p < 0.01).

Conclusion: CH for PHC preserves functional liver reserve, potentially reducing PHLF risk. Adequate preoperative evaluation is crucial, and oncological outcomes require further investigation.

Background: Recent papers report significant survival gain after liver resection in BCLC-B and -C HCC patients. The results of minimally invasive liver surgery (MILS) in such patients have not been widely investigated so far.

Methods: Data regarding patients undergoing MILS or open liver resection (OLR) for HCC staged BCLC -B and -C were extracted from the HERCOLES database. An inverse probability of treatment weighting (IPTW) method was adopted to balance the confounders. The primary outcome was a composite endpoint including post-hepatectomy liver failure, severe postoperative complications and in-hospital mortality.

Results: 627 patients were included (459 undergoing OLR and 168 receiving MILS). After IPTW, no difference was found in the composite endpoint between MILS and OLR (OR 0.86 [95%CI 0.46-1-60]; p = 0.62). MILS reduced the risk of receiving intra-operative transfusions (OR 0.28 [95%CI 0.13-0.58]; p < 0.001) and of developing postoperative ascites (OR 0.56 [95%CI 0,32-0,98]; p = 0.039), with reduced length of stay (OR 0.82 [95%CI 0.66-1.01]; p = 0.045). The survival analysis showed no differences between MILS and OLR for both OS (p = 0.13) and DFS (p = 0.491).

Conclusion: MILS was shown to be safe and feasible for selected non-metastatic HCC patients staged BCLC B and C, reducing the risk of perioperative transfusions and postoperative ascites, and shortening the length of stay.

Introduction: We sought to define a cohort of patients with "biological R2" (bR2) resection, defined as recurrence within 12 weeks, following curative-intent resection for intrahepatic cholangiocarcinoma (ICC). In addition, we sought to identify factors associated with bR2 risk.

Methods: Patients who underwent upfront curative-intent surgery for ICC were identified from an international, multi-institutional database. The weighted beta-coefficients of preoperative risk factors were used to construct an online tool to predict bR2.

Results: Among 1138 patients, 106 (9.3 %) patients had a bR2 resection. Patients with bR2 were more likely to be younger (OR 0.97) and non-White (OR 2.19), as well as more often had cirrhosis (OR 2.11), a higher neutrophil-to-lymphocyte ratio (OR 1.07), a higher tumor burden score (OR 1.16), and metastatic nodal disease on preoperative imaging (OR 1.92). Patients categorized as low-risk had a 3.2 % risk of bR2, intermediate-risk patients had an 11.1 % risk of bR2, whereas patients in the high-risk category had a 27.6 % risk of bR2 (p < 0.001). An online tool was made available at https://junkawashima.shinyapps.io/bR2_ICC/, https://junkawashima.shinyapps.io/CRLMfollwingchemotherapy/.

Conclusions: Approximately one in ten patients with resectable ICC had a bR2 resection. An online calculator can may help clinicians identify patients with ICC at highest risk of a bR2 resection.

Background: Despite the growing interest in liver transplantation for cholangiocarcinomas (CCA), conclusive evidence is lacking. We sought to evaluate the outcomes of liver transplantation for intrahepatic cholangiocarcinoma in Brazil.

Methods: Retrospective database analysis of patients undergoing liver transplantation for hepatocellular carcinoma (HCC) within Milan criteria in São Paulo, Brazil. Anatomopathological examination of the explanted liver with the presence of intrahepatic cholangiocarcinoma (iCCA) or combined hepatocellular-cholangiocarcinoma (cHCC-CCA) comprised the study group (50 patients). They were compared to a 1:3 HCC-matched cohort.

Results: Study group had lower survival rates than HCC controls (survival at 1, 3, and 5 years, 70.0 %, 57.5 %, and 57.5 % versus 78.7 %, 71.4 %, and 66.6 %, p = 0.019). 5-year survival rates of the control group, cHCC-CCA, and iCCA group were 66.6 %, 59.6 %, and 50.0 % (p = 0.017). There was no statistically significant difference in survival for study group patients with tumors up to 3 cm compared to their controls (p = 0.086).

Discussion: Patients with CCA had worse outcomes after liver transplantation than those with HCC. Interesting results were found in the more individualized analyses, but because of the limited number of patients, caution should be taken when analyzing them.

Background: Porto-mesenteric venous resection (PMVR) is employed for advanced pancreatic cancer. When primary anastomosis is not feasible, an interposition graft can be used. At our centre, the left renal vein (LRV) is the preferred choice.

Methods: A retrospective analysis of patients undergoing pancreatic resection was performed over a 6-year period. Patients who underwent LRV harvest for a PMVR interposition graft were identified. All patients underwent a contrast-enhanced CT scan on post-operative day 1 to assess for portal vein thrombosis.

Results: Pancreatic resection with PMVR was performed in 183 patients. LRV graft was used in 41 patients. Severe complications were observed in 10 patients. There were two deaths within 90 days of the index operation and six readmissions within 30 days of discharge. Post-operative PV thrombus was observed in 4 patients. The serum creatinine increased by 15.7 % on POD1 and peaked at 30.8 %. The majority of patients had returned to a serum creatinine within 10 % or better of their pre-operative creatinine.

Conclusion: We present the largest series using the LRV as an interposition graft for PMVR. We propose that the LRV should be used as the first-choice interposition graft. This graft does not cause long-term renal dysfunction and avoids the morbidity of an additional incision.

Background: The demand for liver transplantation is rising, as is the prevalence of steatotic liver disease. Steatotic grafts have inferior outcomes post-transplantation, due to increased sensitivity to ischaemia-reperfusion injury. We aimed to formally evaluate the impact of visually assessed liver steatosis in grafts donated following brainstem (DBD) versus circulatory death (DCD).

Methods: NHS registry on adult liver transplantation was reviewed retrospectively (2006-2019). We used multiple-imputation for missing data and adjusted regression models with interaction terms to compare the impact of visually assessed donor graft steatosis on transplant outcome.

Results: 9217 recipients of deceased donor grafts were included (DBD = 7349; DCD = 1868). Multivariable cox regression revealed that the negative impact on graft survival was significantly different in DCD and DBD livers (interaction P = 0.011 and P = 0.043). The largest impact was in DCD livers (moderate steatosis: aHR = 1.851, 1.296-2.645, P = 0.001 and aHR = 5.426; severe steatosis: 1.723-17.090, P = 0.004). Visually assessed steatosis did not predict longer-term graft survival in the DBD cohort.

Conclusion: The impact of visually assessed steatosis on post-transplant outcome is far greater in DCD grafts, despite an identical method of steatosis assessment. This highlights novel therapeutics should be considered for steatotic DCD grafts to allow this growing sector of the donor pool to be safely utilised.

Background: Liver cirrhosis accounts for more than 90 % of portal hypertension cases, and the other cases are due to noncirrhotic portal hypertension (NCPH). Variceal bleeding is the most life-threatening complication of portal hypertension and its primary treatment is medical according to the Baveno VII guidelines. This review discusses the evidence on surgical portal decompression for adult patients with NCPH secondary to chronic extrahepatic portal vein obstruction (EHPVO).

Methods: This is a scoping review of the evidence for the feasibility and effectiveness of surgical portal decompression in adults with NCPH secondary to EHPVO.

Results: This scoping review yielded 17 studies, including a total of 110 patients. Patient age(s) ranged from 19 to 68 years, with the majority undergoing nonphysiological (i.e., portosystemic shunts) shunts (N = 84, 76.4 %), mostly for variceal bleeding refractory to medical and endoscopic treatments. Physiological shunts (i.e., Rex shunts) had a potential advantage over nonphysiological shunts in postoperative rebleeding (5 % vs. 10 %) and hepatic encephalopathy rates (0 % vs. 13 %). Conversely, nonphysiological shunts had a potential advantage over physiological shunts in postoperative shunt thrombosis (8 % vs. 22 %).

Discussion: This scoping review reported that surgical portal decompression is feasible in adults with NCPH due to EHPVO with favorable outcomes and long-term patency.

Background: The recommended first-line treatment for respectable hepatocellular carcinoma (HCC) is surgical resection, but local ablation has gained popularity as a safe alternative. This study aims to compare the effectiveness of radiofrequency ablation (RFA), microwave ablation (MWA) and high-intensity focused ultrasound (HIFU) as first-line treatments for HCC.

Methods: In this single-centre retrospective study, 352 patients receiving RFA, MWA, or HIFU as first-line treatment for HCC were included. Pre- and post-treatment tumour sizes and overall and disease-free survival rates were analysed to compare the three local ablation modalities. Propensity-score matching was used to reduce the bias due to differences in pre-treatment liver function.

Results: Patients receiving HIFU had significantly higher pre-treatment MELD score and Child-Pugh grade. The complete response rates of HIFU patients were significantly lower than those of RFA and MWA groups (p < 0.001) despite propensity-score matching. However, the three groups had similar disease-free survival (p = 0.216) and comparable one-year survival (p = 0.173).

Discussion: HIFU serves as a last resort rescue therapy for patients with poor pre-treatment liver function who are not eligible for other local ablative means. Despite the low complete response rate, the overall survival and disease-free survival rates of patients having HIFU were comparable to those having RFA or MWA.

Background: Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death globally, particularly in developing countries in Southeast Asia and sub-Saharan Africa (SSA), where chronic hepatitis B virus (HBV) dominates as a major aetiological factor.

Methods: We conducted a retrospective cohort study to quantify the metastatic profile of HCC in a South African patient population managed at a tertiary centre. Demographic, clinical and treatment data were extracted from an institutional registry. Patients with and without metastases were compared to identify factors associated with an increased risk of developing metastases.

Results: Of 676 patients, 194 (28.7 %) had metastases. Patients with metastases were younger (46.37 vs. 52.23 years; p < 0.00001) and more frequently had chronic HBV, HIV co-infection and schistosomiasis compared to non-metastatic patients. The most common metastatic sites were lungs, skeletal, and peritoneum. For non-treated patients, skeletal metastases had the poorest survival.

Conclusion: This study confirms a typical SSA disease profile of aggressive HCC in a young population. We reported on the metastatic profile of HCC and the impact of different metastases on survival. Future research should focus on defining the concept of oligometastatic disease in HCC to identify patients where intervention targeting metastatic disease may be of benefit.