Patient-specific three-dimensional (3D) reconstruction converts cross-sectional imaging into individualised anatomical models of the liver, its vasculature and tumours and is increasingly used to plan hepatectomy. Its appeal is intuitive: it externalises the spatial reasoning that surgeons must otherwise perform mentally from two-dimensional images. Whether that appeal is matched by evidence varies greatly across the pathway from image to outcome. This critical review appraises the evidence chain—acquisition, segmentation, anatomical and quantitative representation, surgical planning, decision correctness, intraoperative translation and clinical benefit—against the reference standards appropriate to each step. The evidence is strongest where a physical referent exists: whole-liver and parenchymal segmentation are reproducible, and whole-liver and future-liver-remnant volumetry are among the best-validated outputs, albeit with characterised systematic and patient-level errors. It weakens progressively for tumour, small-vessel, arterial, biliary and territorial reconstruction and for computed vascular territories, which are inferred rather than directly observed. Reconstruction reliably changes operative plans, but whether those changes are correct is poorly established, and the operation performed is not an independent reference standard. Intraoperative registration remains approximately centimetric in several clinical series, and perioperative outcome and cost-effectiveness evidence is largely observational. The central message is that the maturity of 3D reconstruction is unevenly distributed: technical feasibility and volumetry are comparatively mature, whereas decision correctness, intraoperative validity and demonstrated patient benefit are not. Progress now depends less on more elaborate models than on reference standards, surgically meaningful validation metrics and prospective outcome evidence.
Background and aims: Acute decompensation (AD) of cirrhosis is a critical clinical event with heterogeneous outcomes, ranging from stable decompensated (SD) cirrhosis to acute-on-chronic liver failure (ACLF). Disturbances in the primary and secondary hemostasis have been implicated in the progression of cirrhosis. This study aimed to evaluate changes in primary hemostasis, i.e., VWF parameters, multimer distribution and ADAMTS13 activity in patients who could clinically improve after AD. Methods: Thirty-five cirrhotic patients hospitalized with AD were prospectively assessed at baseline and at 3-month follow-up when they reached an SD state. Clinical and laboratory characteristics, including the MELD score, were evaluated at both time points. VWF level and its different activities were measured using automated immunoassays, ADAMTS13 activity by chemiluminescent assay, and VWF multimer distribution using electrophoresis and densitometry. Results: At AD, at least one organ failure occurred in 13 patients, with 4 patients identified as ACLF grade 1. The MELD score was 22 (IQR 18–25) at AD, while at 3 months (SD) it was 17 (12–20) (p < 0.001). VWF parameters similarly decreased [VWF antigen 530% vs. 409% (p = 0.009), VWF activity 332% vs. 301% (p = 0.038), VWF collagen-binding 399% vs. 308% (p = 0.017)], while ADAMTS13 activity increased from 55% to 84% (p < 0.001). Ultra-large VWF multimers (ULMWM) were detected in six patients during AD but were absent in all SD samples, while ADAMTS13 activity normalized. Conclusions: Our findings demonstrate that the VWF–ADAMTS13 axis in cirrhosis is a dynamically changing marker, and the temporary appearance of ULMWM during AD exposes thrombogenic potential in cirrhosis.
The publication of the joint EASL-EASD-EASO guidance on the use of resmetirom and semaglutide as MASH-targeted therapy represents a watershed moment in hepatology [...]
Background/Objectives: Metabolic dysfunction and alcohol-associated liver disease (MetALD) is characterized by the coexistence of metabolic dysfunction with moderate alcohol consumption. Anthropometric indices have emerged as simple, non-invasive tools for assessing metabolic, cardiovascular, and hepatic steatosis risks; however, their association with MetALD is unclear. We evaluated the association between anthropometric indices and MetALD and assessed their discriminative performance. Methods: We analyzed 2645 NHANES 2017–2020 participants with transient elastography data, including 165 with MetALD. Body roundness index (BRI) was categorized into weighted quartiles. Results: MetALD participants had significantly worse metabolic profiles and higher liver enzymes than controls (all p < 0.001). Severe steatosis increased across BRI quartiles from 1.8% in Q1 to 33.3% in Q4, while fibrosis increased from 0% to 6.7%. Higher BRI quartiles were independently associated with MetALD after adjustment for age, sex, race, BMI, and WC (OR 4, 11.1, and 12.8 for Q2, Q3, and Q4, respectively; all p < 0.012). Non-Hispanic Asian participants had an increased risk of MetALD (OR 3; p = 0.016). Waist circumference (WC) demonstrated the highest discriminative performance for MetALD (area under the curve [AUC] = 0.773), followed by BRI (AUC = 0.743). Gamma-glutamyl transferase (GGT) demonstrated the highest discrimination value (AUC = 0.776) for predicting MetALD, while the combined WC and GGT showed the highest overall performance (AUC of 0.817). Conclusions: Higher BRI is independently associated with MetALD, along with greater steatosis and fibrosis severity. Simple anthropometric measures may aid early identification and risk stratification of MetALD.
Hepatocellular carcinoma (HCC) requires simultaneous management of cancer and the underlying liver disease. As treatment options have increased, stage assignment has become necessary but no longer sufficient for selecting an individual strategy. This narrative review examines the disease continuum, with particular emphasis on treatment allocation, preservation of hepatic reserve, and timely changes in treatment. It compares United States guidance from AASLD and ASCO, European guidance from EASL, the BCLC 2026 strategy, the 2025 Japanese, 2024 Chinese, and 2026 Korean guidelines, and Asia-Pacific recommendations, and identifies both areas of agreement and clinically important differences. Early-stage decisions depend on resectability, portal hypertension, ablation geometry, and transplant access. Intermediate-stage disease requires reassessment of curative options, prospective identification of TACE unsuitability, selective treatment, and explicit stopping rules. TACE-based combinations have improved progression-free survival, but on the evidence available in October 2026, the later EMERALD-1 and LEAP-012 results do not show an overall survival advantage, and EMERALD-3 and TALENTACE leave the balance between survival and toxicity unresolved. Advanced-stage treatment increasingly uses immune checkpoint combinations, selected according to bleeding risk, immune contraindications, tumour distribution, and patient priorities rather than cross-trial survival rankings. Evidence for sequencing after immunotherapy and for patients with impaired liver function remains limited. In IMbrave251, continuing atezolizumab after progression did not improve survival, and patients with Child–Pugh B cirrhosis survive roughly half as long as patients in registration trials. Differences between guidelines reflect publication dates, evidence thresholds, and health system constraints, as well as differences in clinical philosophy. A practical multidisciplinary approach should document therapeutic intent, the reason for choosing one option over alternatives, anticipated harm, the first reassessment, and the trigger for switching or stopping treatment.
