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Background After comparing with open approach, left lateral sectionectomy (LLS) has become standard in terms of short-term outcomes without jeopardizing long-term survival when performed for malignancy. The aim of this study was to compare the short-term and economic outcomes of laparoscopic (L-LLS) and robotic (R-LLS) LLS. Methods All consecutive patients who underwent L-LLS or R-LLS from 1997 to 2014 were analyzed. Short-term and economic outcomes were compared between the two groups using a propensity score matching (PSM). Results Ninety-six consecutive cases of LLS were performed using the laparoscopic (80 cases; 83 %) or robotic (16 cases; 17 %) approach. The two groups were similar for operative and surgical outcomes. Operation time was similar in the R-LLS compared to the L-LLS group (190 vs. 162 min; p  = 0.10). Perioperative costs were higher (1457 € vs. 576 €; p  < 0.0001) in the R-LLS group than in the L-LLS group; however, postoperative costs were similar between the two groups (4065 € in the R-LLS group vs. 5459 € in the L-LLS group; p  = 0.30). Total costs were similar between the two groups (5522 € in the R-LLS group vs. 6035€ in the L-LLS group; p  = 0.70). The PSM included 14 patients for each group. Surgical and economic outcomes remained similar after PSM, except for total operating time which was significantly longer in the R-LLS group than in the L-LLS group. Conclusions Even if feasible and safe, the robotic approach does not seem so far to offer additional benefit in terms of intra- and postoperative outcomes over the laparoscopic approach in patients requiring LLS. Total costs associated with the R-LLS group are not greater than that associated with the L-LLS group, which is the standard of care so far.

BackgroundKnowledge regarding the feasibility and safety of sleeve gastrectomy (SG) in obese liver transplant recipients is scarce. We report our experience of sleeve gastrectomy following liver transplantation (LT).MethodsAll patients who had undergone LT and subsequently underwent SG at our institution were retrospectively reviewed. Surgical outcomes, liver and kidney function tests, outcomes of obesity-related comorbidities, and excess weight loss were analyzed.ResultsBetween May 2008 and February 2015, six consecutive patients underwent SG after LT. Three procedures (50%) were performed totally by laparoscopy, and three by upfront laparotomy for concomitant incisional hernia complex repair. Within the first 30 days, one complication occurred: early gastric fistula that required multiple endoscopic procedures and re-intervention, followed by death 19 months after SG due to multi-organ failure. Another patient had one late complication: chronic infection on a parietal mesh successfully controlled by mesh removal. Excess weight loss averaged 76% at 2 years with a median BMI of 28 (21–39) kg/m2. Median follow-up was 37.2 months (range 13–101 months). Median length of stay was 9 days (range: 6–81 days).ConclusionsSG is technically feasible after LT and resulted in weight loss without adversely affecting graft function and immunosuppression. However, morbidity and mortality are high.

MicroRNAs have emerged as potential biomarkers of liver injury during organ transplantation due to their specificity, easy detection and stability in many biofluids. Heparin, which has a well-known inhibitory effect on RT-qPCR based measurements, is commonly used during organ donation. Heparinase I treatment has been used to overcome the inhibiting effect of heparin in RNA RT-qPCR analysis. However, there is a lack of evidence regarding its effective, feasible use improving specific miRNA quantification yield in the liver transplant setting. The aim of this study is to evaluate the effect of heparinase I on miRNA detection levels by RT-qPCR in different samples from liver donors. Prospective, single-centre study including evaluation of liver biopsy, perfusate fluid and serum from deceased organ donors from October 2019 to May 2021. Samples from brain death donors (DBD, n = 4) and donors after circulatory death recovered with abdominal normothermic regional perfusion (DCD n = 4) were analysed for the presence of liver-injury related miRNAs (miR-122 and miR-148a) in the absence or presence of heparinase I (6 IU or 12 IU) to evaluate its effect on miRNA detection levels by RT-qPCR. A subgroup of heparinized serum samples from patients undergoing cardiopulmonary bypass was analysed for validation purposes. The study is registered with ClinicalTrials.gov (NCT06611046), and accrual is complete. The expression of miR-122 relative to reference genes was 44.5, 16.8 and 4.2-fold higher in liver biopsy, perfusates and serum respectively, while miR-148a was 3.4, 2.2 and 2.6-fold higher, without differential expression between donor groups (p > 0.05). Heparinase I treatment did not improve PCR results and affected miRNA detection yields in a dose-dependent way with delayed and dispersed Ct values. In highly heparinized DCD serum samples, heparinase I treatment significantly reduced the relative expression of miR-122 and miR-148a compared to non-treated samples, 2-fold and 6.1-fold, p < 0.05 respectively. Moreover, treatment with heparinase I led to a rise in lost values, from 12.5% to 25% in perfusates and 67.7% to 68.7% in serum samples treated with 6IU and 12IU of heparinase I respectively. The need for heparinase I treatment to overcome RNA quantification interference in heparinized samples should be addressed in each individual analysis. Heparin inhibition seems variable among miRNAs, and the additional handling with heparinase may affect reliable miRNA quantification due to RNA degradation, introducing bias in gene expression interpretation.

Tacrolimus (TAC) is a dose‐dependent immunosuppressor with considerable intrapatient variability (IPV) in its pharmacokinetics. The aim of this work is to ascertain the association between TAC IPV at 6 months after liver transplantation (LT) and patient outcome. This single‐center cohort study retrospectively analyzed adult patients who underwent transplantation from 2015 to 2019 who survived the first 6 months with a functioning graft. The primary end point was the patient’s probability of death and the secondary outcome was the loss of renal function between month 6 and the last follow‐up. TAC IPV was estimated by calculating the coefficient of variation (CV) of the dose‐corrected concentration (C0/D) between the third and sixth months post‐LT. Of the 140 patients who underwent LT included in the study, the low‐variability group (C0/D CV < 27%) comprised 105 patients and the high‐variability group (C0/D CV ≥ 27%) 35 patients. One‐, 3‐, and 5‐year patient survival rates were 100%, 82%, and 72% in the high‐variability group versus 100%, 97%, and 93% in the low‐variability group, respectively (p = 0.005). Moreover, significant impaired renal function was observed in the high‐variability group at 1 year (69 ± 16 ml/min/1.73 m2 vs. 78 ± 16 ml/min/1.73 m2, p = 0.004) and at 2 years post‐LT (69 ± 17 ml/min/1.73 m2 vs. 77 ± 15 ml/min/1.73 m2, p = 0.03). High C0/D CV 3–6 months remained independently associated with worse survival (hazard ratio = 3.57, 95% CI = 1.32–9.67, p = 0.012) and loss of renal function (odds ratio = 3.47, 95% CI = 1.30–9.20, p = 0.01). Therefore, high IPV between the third and sixth months appears to be an early and independent predictor of patients with poorer liver transplant outcomes.

Background The French transplant governing system defined “Rescue” (the so-called “ Hors Tour ”) livers as those livers which were declined for the five top-listed patients. This study compares the outcomes following liver transplantation (LT) in patients who received a donor liver through a rescue allocation (RA) procedure or according to MELD score priority (standard allocation, SA) and evaluates the impact on the graft pool of a proactive policy to accept RA grafts. Methods Data from all consecutive patients who underwent LT with SA or RA grafts from 2011 to 2015 were compared in terms of short- and long-term outcomes. Results The 249 elective first LTs were performed with 64 (25.7%) RA and 185 (74.3%) SA grafts. RA grafts were obtained from older donors and were associated with a longer cold ischemia time. Recipients of RA livers were older and had lower MELD scores. The rates of delayed graft function, primary nonfunction, retransplantation, complications, and mortality were similar between the RA and SA groups. At 1 and 3 and 5 years, graft and patient survival rates were similar between the groups. These results were maintained after matching on recipient characteristics. Our proactive policy to accept RA grafts increased the liver pool for elective first transplantation by 25%. Conclusions RA livers can be safely transplanted into selected recipients and significantly expand the liver pool.

Background The optimal strategy in patients with stage IVA colorectal cancer remains debated. This study was designed to compare the long-term outcomes and the pattern of recurrence following classical (CS) versus reverse (RS) strategy. Methods Data from all consecutive patients, who have completed the CS and RS, were retrospectively reviewed. A propensity score matching (PSM) was performed on 1:2 (RS:CS) ratio to obtain two groups matched for tumor characteristics. Survival and recurrence pattern were investigated before and after matching. Results The study population included 161 patients: 145 treated with CS versus 16 with RS. Five-year overall survival (OS, 51.5 vs. 42.7 %, p  = 0.91) and recurrence-free survival (RFS, 20.5 vs. 20.6 %, p  = 0.15) were not different between the two strategies. The median time to recurrence (TTR) whatever the site was significantly shorter in the RS group than in the CS group (3.5 vs. 13 months, p  = 0.02). Extrahepatic recurrence was significantly more frequent (37.5 vs. 16.6 %; p  = 0.04) and occurred earlier after treatment completion in the RS group than in the CS group (3.4 vs. 16.4 months, p  = 0.009). Similar findings in terms of OS, RFS, median TTR whatever the site and proportion of extrahepatic recurrence were observed after PSM. Conclusions Stage IVA colorectal cancer patients who have completed the CS or RS had similar OS. Extrahepatic recurrence is more frequent and occurs earlier after RS. Postoperative locoregional therapy and active follow-up strategies should be considered in RS patients.

Background The impact of postoperative complications (POCs) on long-term outcomes following hepatocellular carcinoma (HCC) resection remains to be ascertained. Methods All consecutive HCC resected at a single center were analyzed. Patients with POCs, classified according to Clavien classification, were compared to those without in terms of demographics, pathology, management, overall survival (OS), and disease-free survival (DFS). Independent prognostic factors of POCs were identified using multivariable regression models. Results Among 341 patients, overall POCs rate was 34% ( n  = 116) and grade III–IV POCs rate was 14.4% ( n  = 49). POCs were an independent negative factor for OS [hazard ratio (HR) 1.40, 95% confidence interval (CI) 1.12–2.26, p  = 0.009] with BCLC stage, the need for combined procedure, intraoperative transfusion, and the METAVIR score of the underlying parenchyma. Similarly, occurrence of POCs was associated independently with DFS (HR 1.59, 95% CI 1.18–2.15, p  = 0.002), together with the presence of portal hypertension, BCLC stage, the need for combined procedure, intraoperative transfusion, and the presence of satellite nodules. After stratification, the negative impact of morbidity on OS and DFS reached statistical significance in the BCLC stage A subset only ( p  = 0.026, and p  < 0.001, respectively). Open resection, intraoperative transfusion, and the existence of underlying liver injury were independent predictors of POCs. Conclusions POCs should be considered as a long-term prognostic factor. Careful patient selection requiring underlying liver assessment and appropriate strategy, such as mini-invasive surgery and restricted transfusion policy, might be promoted to prevent POCs.

IntroductionLiver tumours are a leading cause of global morbidity and mortality. Current diagnostic tools, including computed tomography (CT), magnetic resonance imaging (MRI) and intraoperative ultrasound (IOUS), have limitations in detecting liver neoplasms. Indocyanine green (ICG) has emerged as a promising tool for improving liver tumour detection. This study aims to assess the impact of preoperative ICG on intraoperative tumour detection in minimally invasive surgery and develop a machine-learning algorithm to enhance tumour detection using ICG fluorescence.Methods and analysisThis prospective, multicentre, phase IV clinical trial adheres to Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines. Patients with liver tumours eligible for minimally invasive surgery and a preoperative imaging test will be included. ICG will be administered intravenously 24 hours before surgery. Intraoperative procedures will include IOUS, ICG mapping and photographic documentation. Patients will be followed for 90 days to assess tumour progression, morbidity and mortality. The photographic analysis will enable the development of an artificial intelligence algorithm using machine learning and neural networks to identify lesions based on ICG fluorescence. The estimated sample size is 173 patients and the trial is predicted to accrue in 3 years.Ethics and disseminationThe trial will be conducted in accordance with the Declaration of Helsinki and the Spanish Agency of Medicines and Medical Devices (AEMPS) guidelines. Approved by the local institutional Ethics Committee and the AEMPS, the results will be shared with the scientific community through publications and conferences.EudraCT number2023–5 08 316-27-00.Trial registration numberNCT06398028.Protocol versionV.12, 18 March 2025

BackgroundArtificial intelligence (AI) is becoming more useful as a decision-making and outcomes predictor tool. We have developed AI models to predict surgical complexity and the postoperative course in laparoscopic liver surgery for segments 7 and 8.MethodsWe included patients with lesions located in segments 7 and 8 operated by minimally invasive liver surgery from an international multi-institutional database. We have employed AI models to predict surgical complexity and postoperative outcomes. Furthermore, we have applied SHapley Additive exPlanations (SHAP) to make the AI models interpretable. Finally, we analyzed the surgeries not converted to open versus those converted to open.ResultsOverall, 585 patients and 22 variables were included. Multi-layer Perceptron (MLP) showed the highest performance for predicting surgery complexity and Random Forest (RF) for predicting postoperative outcomes. SHAP detected that MLP and RF gave the highest relevance to the variables “resection type” and “largest tumor size” for predicting surgery complexity and postoperative outcomes. In addition, we explored between surgeries converted to open and non-converted, finding statistically significant differences in the variables “tumor location,” “blood loss,” “complications,” and “operation time.”ConclusionWe have observed how the application of SHAP allows us to understand the predictions of AI models in surgical complexity and the postoperative outcomes of laparoscopic liver surgery in segments 7 and 8.

BackgroundStudies comparing hand-assisted laparoscopic (HALS)/Hybrid and pure laparoscopic (PLS) resection for colorectal cancer liver metastasis have focused on short-term results, while long-term oncological outcomes remain understudied.MethodsWe established a multi-institutional retrospective cohort study from four centers with experience in minimally invasive surgery between 2004 and 2020. Primary endpoints were overall survival (OS) and disease-free survival (DFS). Other endpoints analyzed were intraoperative and postoperative outcomes. Propensity score matching (PSM) was used to minimize baseline differences.ResultsA total of 219 HALS/Hybrid (57.8%) and 160 PLS (42.2%) patients were included. After PSM, 155 patients remained in each group. Operative time (182 vs. 248 min, p = 0.012), use of intraoperative ablation (12.3 vs. 4.5%, p = 0.024), positive resection margin (4.5 vs 13.2%, p = 0.012), and pringle time (21 vs. 37 min, p = 0.001) were higher in PLS group. DFS at 1, 3, 5, and 7 years in HALS/Hybrid and PLS groups were 65.4%, 39.3%, 37.5%, and 36.3% vs. 64.9%, 38.0%, 33.1%, and 33.1%, respectively (p = 0.84). OS at 1, 3, 5, and 7 years in HALS/Hybrid and PLS groups were 94.5%, 71.4%, 54.3%, and 46.0% vs. 96.0%, 68.5%, 51.2%, and 41.2%, respectively (p = 0.73).ConclusionOur study suggests no differences in long-term oncologic outcomes between the two techniques. We discovered that longer total operative, pringle time, higher rates of intraoperative ablation, and positive resection margins were associated with PLS. These differences in favor of HALS/Hybrid could be due to a shorter learning curve and a greater ability to control hemorrhage.