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Background: Postoperative pancreatic fistula (POPF) remains a major complication following pancreaticoduodenectomy (PD). Indocyanine green (ICG) fluorescence angiography offers real-time perfusion assessment but is underutilized in pancreatic surgery. Although pancreatic stump hypoperfusion has been suggested as a risk factor for POPF, but its role remains underexplored.

Objective: To evaluate whether quantitative perfusion parameters derived from ICG fluorescence angiography are associated with POPF.

Methods: In this prospective cohort study, 30 patients undergoing PD were assessed using ICG near-infrared fluorescence angiography. Fluorescence intensity-time curves were generated using a Python-based algorithm and analyzed for intensity and flow parameters. Associations between perfusion metrics and POPF, classified by ISGPS criteria, were statistically evaluated.

Results: Clinically relevant POPF (CR-POPF) occurred in 30 % of patients. Significant associations were observed between CR-POPF and perfusion parameters including higher fluorescence distribution heterogeneity (p = 0.032) and a slower slope of fluorescence increase (p = 0.008).

Conclusions: Quantitative ICG fluorescence angiography provides objective metrics that correlate with POPF development. Parameters such as slope, peak intensity and fluorescence heterogeneity may serve as intraoperative indicators of perfusion adequacy, supporting surgical decision-making during PD. Larger, multicenter studies are warranted to validate these findings.

Background: Despite growing adoption of the Heidelberg TRIANGLE operation for pancreatic head/body tumors, comprehensive analysis of its safety and outcomes remains lacking.

Methods: Systematic searches using predefined criteria (inception-May 2024) across PubMed, Cochrane, Web of Science, Embase, Medline, CNKI and Wan-Fang databases identified eligible studies. Primary outcomes were R0 resection rates and survival; secondary outcomes were complications and recurrence. Meta-analysis utilized Stata 18.0.

Results: This meta-analysis included 8 studies (1,106 patients). Compared to standard resection, the TRIANGLE group had longer operative times and higher postoperative diarrhea rates (P < 0.001), but demonstrated reduced 1-year (P = 0.001) and 3-year recurrence (P = 0.036), lower perioperative mortality (P = 0.032), and more extensive lymph node dissection (P = 0.004). No differences were observed in R0 rates (P = 0.171), survival (1-year P = 0.730; 3-year P = 0.136), or primary complications. Overall survival (P = 0.075) and recurrence rates (P = 0.137) showed no statistical significance.

Conclusion: TRIANGLE operation reduces 1/3-year recurrence rates vs standard resection but increases postoperative diarrhea, while achieving similar R0/R1 rates and survival outcomes. Its clinical benefits require validation through large multicenter RCTs.

Background: Refinement in perioperative chemotherapy coupled with surgical innovation improves prognosis in children with very high risk hepatoblastoma. Our aim was to evaluate and identify prognostic factors contributing to recurrence in hepatoblastoma resected along with adjacent structures.

Methods: An audit was conducted of patients surgically treated for hepatoblastoma at our center over 25 years.

Results: Thirty-six of 202 patients underwent resection of structures adjacent to the liver for suspected tumor spread. Over half (21/36) of patients underwent hepatectomy with resection of adjacent structures, and orthotopic liver or multi-visceral transplantation. Adjacent structures including lymph nodes, vascular structures, diaphragm, spleen, omentum, and stomach, showed viable tumor tissue in nineteen patients. Both overall survival and recurrence free survival were 75 % at a mean follow up of 113 months. Survival improved with a negative resection margin. Recurrence free survival decreased with tumor viability. Pathology subtypes showed distinct influence on survival.

Conclusion: This series shows favorable survival with aggressive surgical treatment. Adverse histology subtype, lung metastases, and resistance to chemotherapy are associated with higher risk of recurrence. Management at specialist centers with simultaneous hepatic resection and transplantation readily available, achieves optimum outcomes in this niche subgroup of children with advanced hepatoblastoma.

Background: Subtotal cholecystectomy (StC) is a recognised bail-out strategy for difficult cholecystectomy. The aim of the study was to analyse technical aspects and outcomes associated with subtypes of StC.

Method: All perioperative data of patients who underwent StC at Christchurch Hospital between June 2015 to September 2023 were retrospectively identified and analysed. The subtypes were classified as reconstituting (rStC), fenestrating (fStC), and remnant posterior wall (pwStC) subtotal cholecystectomy.

Results: Of the 6251 patients who underwent cholecystectomy, 422 (6.8 %) underwent StC, and 132 (31.3 %), 115 (27.3 %), 175 (41.5 %) underwent rStC, fStC and pwStC respectively.pwStC was generally associated with superior, and fStC inferior outcomes. In patients who had fStC, rStC and pwStC; 38 (33.0 %), 12 (9.1 %), 6 (3.4 %) developed bile leak (p < 0.001), 20 (17.4 %), 12 (9.1 %), 3 (1.7 %) developed intraabdominal collections (p < 0.001), and 28 (24.3 %), 10 (7.6 %) and 9 (5.1 %) required post-operative ERCP (p < 0.001), respectively. No difference in rates of delayed post-op biliary events including cholecystitis and choledocholithiasis were noted across the subgroups (p = 0.775).

Conclusion: There are technical variations of StC with different complication profiles. Surgeons should be aware of these nuances, as it may help inform decision making when faced with need to perform StC.

Background: Postoperative complications (POC) in surgery for hepatic cystic echinococcosis (HCE) still being frequent. Comorbidities as a risk factor has not yet been studied. The aim of this study was to evaluate the predictive value of CCI for POC in surgically treated HCE patients.

Methods: Nested case-control study. Patients undergoing elective surgery for HCE between 2011 and 2019; matched (1:1) by sex, cyst diameter and time follow-up were included. Cases were patients with CCI≥3; and controls, patients with CCI≤2. Primary outcome was POC. Descriptive statistics and bivariate analyses were applied. Logistic regression was used, odds ratios (OR) and their respective 95 % confidence intervals (CI95 %), were calculated.

Results: 226 patients (113 cases and 113 controls) were analyzed. Significant differences were verified between cases and controls in frequency of evolutionary complications of HCE (OR: 5.5; p = 0.0003); and major rate of ASA I-II in controls (OR: 0.07; p < 0.0001). A great rate of POC (OR: 3.58; p = 0.0002); and Clavien ≥ IIIb POC more frequent in cases were found (OR: 7.00; p = 0.031). Applying logistic regression model, CCI score≥3 was identified as an independent prognostic factor for POC (OR: 6.29 [CI95 %: 2.1-18.8; p < 0.01]).

Conclusion: In this study, cases showed higher frequency and severity of POC than controls.

Background: A universally accepted quality measure for gallstone surgery is lacking. In this retrospective study, we evaluated the duration of postoperative care, completion with laparoscopic approach, absence of procedure-related complications, and no readmission as criteria for Textbook Outcome (TO).

Methods: Data was collected from the Swedish National Register for Gallstone Surgery (GallRiks) 2007-2022. We analyzed postoperative stay as exposure and postoperative complications as outcome using Receiver Operation Characteristic (ROC). TO was defined as laparoscopically completed operations, discharge within three days after surgery, no postoperative complication > Clavien-Dindo 2, no contact with the care provider or new readmission/intervention within 30 days post-surgery. The outcome of TO was further validated based on patients 6 months postoperatively answering SF-36.

Results: A total of 193 201 cholecystectomies were analyzed. Using discharge within three days postoperatively as threshold, the sensitivity was 50 % and the specificity 87 % for predicting a surgery-related complication. The rate of TO in the entire cohort was 79,4 %. Those who met the TO criteria rated notably higher on physical and mental scoring 6 months postoperatively (both p < 0.05) than those who did not.

Conclusion: The postoperative period of care and TO are robust outcome measures for evaluating results after gallstone surgery.

Background: The aim of theis study was toevaluate impact of duration of neoadjuvant treatment (NAT) on surgical resection rate, resection margin, response to treatment, and survival in patients with pancreatic ductal adenocarcinoma (PDAC).

Methods: All randomised controlled trials (RCTs) of NAT in patients with PDAC were included. Effect sizes were determined for surgical resection rate, R0 resection, radiological response to NAT and 1- to 5-years survival.

Results: Twenty-three RCTs (1880 patients) were included. NAT duration≤8 weeks was associated with significantly higher surgical resection rate [66.7 % (95 % CI 57.4 %-76.1 %)] compared with NAT duration >8 weeks [33.5 % (95 % CI 22.1 %-45.0 %)]. The difference remained significant when only resectable [73.9 % (95 % CI 64.3 %-83.5 %) vs 44.7 % (95 % CI 15.9 %-60.6.%)], borderline resectable [66.4 % (95 % CI 46.6 %-86.1 %) vs 22.5 % (95 % CI 18.2 %-26.8 %)], or mixed borderline resectable/locally advanced PDAC [60.6 % (95 % CI 48.2 %-73.0 %) vs 35.0 % (95 % CI 27.6 %-42.4 %)] were considered. Moreover, when only NAT with chemotherapy considered, resection rate remained significant in favour of NAT duration≤8. No significant difference was found in R0 resection rate, partial response, stable disease, or disease progression between two groups. Intention-to-treat respected 1-, 3-, 5-years survival were comparable.

Conclusions: NAT duration >8 weeks may be associated with a reduced surgical resection rate and no apparent improvement in negative resection margin in patients with PDAC, particularly borderline resectable cases. However, it may have comparable survival to NAT duration ≤8 weeks. Future randomised evidence is needed to overcome the limitations associated with current evidence.