Hepaticojejunostomy after biliary tract tumors resection represents the main limitation to minimally invasive approaches application in this field. Robotic surgery is emerging as an attractive option, offering enhanced three-dimensional visualization and articulated instruments that allow for precise intracorporeal suturing. We present our series of robotic hepaticojejunostomy with Witzel-style transanastomotic stenting. This dynamic manuscript provides a comprehensive overview of the robotic Witzel technique hepaticojejunostomies, focusing on technical aspects and postoperative outcomes. Nine patients underwent a robotic Witzel-hepaticojejunostomy, eight for oncologic diseases. Surgical procedures included four bile duct resections alone and four associated with major hepatectomies. All hepaticojejunostomy were built upon a Roux-an-Y jejunal loop, with an antecolic path in seven cases. The prevalent suturing technique was a mixed technique, combining continuous barbed suture for one wall with an interrupted suture for the other. The median operative time was 630 min (593–705), median blood loss was 100 ml (100–350), and no intraoperative blood transfusions were required. Postoperative complications occurred in 3 patients (Clavien-Dindo 3a), without any post-hepatectomy liver failure nor biliary complications. R0 was achieved in 6 out of 8 curative resections and median retrieved nodes were 8.5 (4.5–16.3). After a mean follow-up of 12.6 ± 8 months, 4 (50

BACKGROUND:hypertrophy techniques expanded surgical indications, but some patients still experience limited clinical benefit. We aimed to identify futility predictive factors in major hepatectomies after liver venous deprivation (LVD) or ALPPS-variants (tourniquet-ALPPS or hybrid-ALPPS). METHODS:a bi-institutional cohort study conducted between 01/2015 and 07/2024 including major hepatectomies for oncologic disease following one of the three augmentation strategies. EXCLUSION CRITERIA:age <18, benign pathology, follow-up < 6-months, and interstage dropout. Futility corresponded to 90-days mortality or very early recurrence (≤6 months). Predictors of futile outcomes were identified by uni- and multi-variate analyses and utilized to build a futility score (0-10). RESULTS:84 patients completed the surgical process (dropout rate: 21.1 %): 40.5 % underwent LVD, 33.3 % tourniquet-ALPPS, and 26.2 % hybrid-ALPPS. Futility was observed in 35 patients (41.7 %) and logistic regression identified baseline sFLR (OR 0.89, p = 0.013), associated procedures (OR 3.07, p = 0.046), right trisectionectomy (OR 5.61, p = 0.031), and non-radical resection (OR 4.31, p = 0.01) as independent predictors. A futility score ≥4 (n = 36) predicted a futile outcome with good discrimination (AUC 0.802; p < 0.001). CONCLUSION:Technical success after hypertrophy techniques not always equates clinical benefit. Recognizing predictors of futility may improve patient selection and guide more personalized therapeutic strategies.

Optimizing future liver remnant (FLR) volumes is crucial for safe major liver resections; liver venous deprivation (LVD) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) variants (vALPPS) are widely used techniques to address this issue, but direct comparisons are limited. The study aimed to evaluate their perioperative and oncological outcomes. This was a retrospective cohort study on consecutive patients undergoing liver hypertrophy between January 2015 and July 2024 conducted at two referral centers. A total of 84 patients, according to exclusion criteria, completed the procedure (drop-out rate: 21.1

3560 Background: Laparoscopic surgery for colorectal liver metastases (CRLM) is associated with lower physical impact, shorter length of stay and less postoperative morbidity than open surgery. To analyze oncological and procedural outcomes, a European consortium including principal investigators of all 4 completed RCTs on laparoscopic (LLR) vs open (OLR) liver resection performed an individual participant data meta-analysis (IPDMA), including updated survival data. Methods: This was an IPDMA with a primary endpoint of postoperative morbidity. Secondary endpoints included overall survival (OS), disease-free survival (DFS) and resection margin status. A generalized linear mixed model was used to compare OLR and LLR , with trial as a fixed-effect. Logistic regression analysis was performed for dichotomous variables and negative binominal regression analysis for continuous variables. Survival analyses were performed using Cox-regression. Results: A total of 761 patients with CRLM were randomly allocated to LLR (n = 384) or OLR (n = 377). Preoperative chemotherapy was administered as recommended by the local multidisciplinary team (40% vs 46%). Whilst LLR was associated with significantly less postoperative morbidity overall (19% vs 27%, adjusted OR 0.62 [95%CI 0.44 to 0.88]), this was not observed in the subgroup of patients receiving neoadjuvant chemotherapy (25% vs 24%, adjusted OR 1.06 [95%CI 0.63 to 1.79]), p-value for interaction < 0.001). Hospital stay was shorter after LLR (median 4 vs 5 days, adjusted percentage difference: -27 [95%CI -37 to -15]) All cause 90-day mortality was not significantly different (1.9% vs 0.8%, adjusted OR: 3.2 [95%CI 0.65 to 16.00]). At 5-year follow-up OS and DFS were not significantly different (adjusted HR 0.97 [95%CI 0.79 to 1.20] and 1.05 [95%CI 0.86 to 1.27], respectively). In patients who received preoperative chemotherapy, a trend towards fewer R0 resections in LLR compared to OLR was noted (84% vs 90%, adjusted OR 2.00 [95%CI 0.99 to 4.03], p-value for interaction = 0.053). In patients who did not receive preoperative chemotherapy there was no difference in R0 resections (90% vs 86%, adjusted OR 0.76 [95%CI 0.41 to 1.40]). Liver specific recurrence was not different between LLR and OLR (37% vs 37%, adjusted OR 1.02 [95%CI 0.76 to 1.34), neither was time to adjuvant chemotherapy (45 days vs 49 days, adjusted OR 1.12 [95%CI 0.91 to 1.38]) nor median number of adjuvant courses (8 vs 8, adjusted percentage difference 0.07 [95%CI -0.11 to 0.24]). Conclusions: This IPDMA of 761 patients in 4 RCTs across Europe confirms that laparoscopic resection for CRLM is superior to open resection with regards to short term outcomes, with no differences observed on long term oncological outcomes. However, in patients who received preoperative chemotherapy, the benefit of the laparoscopic approach is questionable.

The integration of robotic systems in liver surgery has evolved significantly, necessitating an evaluation of their impact on surgical outcomes and patient quality of life. This study aims to analyze the effect of the Da Vinci Xi robotic system on the recovery of quality of life in patients undergoing liver surgery. A prospective study was conducted involving patients who underwent robotic liver surgery between October 2021 and February 2023. Socio-demographic, clinical, and quality of life data using the SF-36 questionnaire were collected. Variables were assessed preoperatively and at one and four months post-surgery. The robotic surgery group exhibited enhanced bodily pain scores at one month postoperatively (55.3 vs. 38.4, p = 0.014). Comparison of preoperative and one-month postoperative scores indicated similar health outcomes in the robotic group alongside improved self-reported health (39.2 vs. 32.2, p = 0.045). Conversely, the open surgery group experienced declines in physical function, bodily pain, vitality, social function, and physical component scores. At four months, the robotic group demonstrated marked improvements in physical role, social function, mental health, self-reported health, and mental component scores. Our findings suggest that robotic surgery facilitates a more favorable recovery in quality of life, with patients returning to pre-surgery levels of well-being by one month postoperatively, in contrast to the outcomes associated with open surgery.

BACKGROUND:Surgical management of perihilar cholangiocarcinoma (pCCA) is one of the most challenging procedures within hepatobiliary surgery. Robotic platform, with its intrinsic advantages, is emerging as a promising tool for these complex procedures. The aim of the study was to compare perioperative outcomes of robotic and open resections of pCCA. METHODS:Retrospective, single-referral center, observational study comparing preoperative, intraoperative, and postoperative outcomes between the first 10 consecutive robotic resections and the last 20 consecutive open resections of histologically confirmed pCCA. All cases were potentially candidates for both approaches. Exclusion criteria were palliative resections, unresectable/metastatic disease, associated vascular resections, concomitant malignancies or prior major hepatectomy. RESULTS:Baseline characteristics were similar between the open and robotic groups, with a median age of 69 years, a predominance of male (73%) and a homogeneous representation of Bismuth type (I-23%; II-13%; IIIa-13%; IIIb-27%; IV-23%). The only preoperative difference was the use of bilateral biliary drains exclusively in the open group (p = 0.029). Intraoperatively, robotic approach required less blood transfusions (p = 0.038) and allowed more extended lymphadenectomies (p = 0.001), with a consequently higher number of retrieved nodes (median 9 [6-16] vs. 4 [2-8], p = 0.022), at cost of longer operative time (660 vs 345 min, p < 0.001). Postoperative complications, 90-days mortality rates and hospital stay were comparable (p = 0.175, p > 0.99 and p = 0.055). CONCLUSIONS:Robotic-assisted resection for pCCA appears to be a feasible and safe approach in selected patients and experienced hands, offering potential advantages over open surgery.

BACKGROUND:Iatrogenic bile duct injury (BDI) during cholecystectomy is associated with a complex and heterogeneous management owing to the burden of morbidity until their definitive treatment. This study aimed to define the textbook outcomes (TOs) after BDI with the purpose to indicate the ideal treatment and to improve it management. METHODS:We collected data from patients with an BDI between 1990 and 2022 from 27 hospitals. TO was defined as a successful conservative treatment of the iatrogenic BDI or only minor complications after BDI or patients in whom the first repair resolves the iatrogenic BDI without complications or with minor complications. RESULTS:We included 808 patients and a total of 394 patients (46.9%) achieved TO. Overall complications in TO and non-TO groups were 11.9% and 86%, respectively (P < .001). Major complications and mortality in the non-TO group were 57.4% and 9.2%, respectively. The use of end-to-end bile duct anastomosis repair was higher in the non-TO group (23.1 vs 7.8, P < .001). Factors associated with achieving a TO were injury in a specialized center (adjusted odds ratio [aOR], 4.01; 95% CI, 2.68-5.99; P < .001), transfer for a first repair (aOR, 5.72; 95% CI, 3.51-9.34; P < .001), conservative management (aOR, 5.00; 95% CI, 1.63-15.36; P = .005), or surgical management (aOR, 2.45; 95% CI, 1.50-4.00; P < .001). CONCLUSION:TO largely depends on where the BDI is managed and the type of injury. It allows hepatobiliary centers to identify domains of improvement of perioperative management of patients with BDI.

Background Artificial 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. Methods We 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. Results Overall, 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.” Conclusion We 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.

Next generation modelling 3D devices and simulation with Virtual Reality (VR) glasses represent a new tool that can be used to improve the understanding of hepatobiliary surgery in medical students. Between September 2022 and January 2024, we conducted a prospective study among 4th year medical students. A new teaching methodology based on technological innovations centered on state-of-theart 3D was implemented. A survey was used to evaluate satisfaction, usefulness, improvement, implementation, comprehension and motivation indexes. A total of 46 students answered the questionnaire. A total of 95.7% agreed that the 3D virtual models and VR favored a greater interest in the class, with no unfavorable response in this respect. 95.7% agreed that the use of 3D printed models should have a greater presence in surgery classes. A 97.8% agreed that surgical videos assisted by 3D reconstructions should have more presence in the classroom. The results of this study support the effectiveness and acceptance of 3D technology -based teaching methodology in the teaching of hepatic surgical anatomy.

Next generation modelling 3D devices and simulation with virtual reality glasses represent a new tool that can be used to improve the understanding of hepatobiliary surgery in medical students. Between september 2022 and january 2024 we conducted a prospective study among 4th year medical students. A new teaching methodology based on technological innovations centered on state-of-the-art 3D was implemented. A survey was used to evaluate satisfaction, usefulness, improvement, implementation, comprehension and motivation indexes. A total of 46 students answered the questionnaire. A total of 95.7% agreed that the 3D virtual models and virtual reality favored a greater interest in the class, with no unfavorable response in this respect. 95.7% agreed that the use of 3D printed models should have a greater presence in surgery classes. A 97.8% agreed that surgical videos assisted by 3D reconstructions should have more presence in the classroom. The results of this study support the effectiveness and acceptance of 3D technology-based teaching methodology in the teaching of hepatic surgical anatomy. Los nuevos dispositivos de modelización 3D de última generación y simulación con gafas de realidad virtual suponen una nueva herramienta que puede ser utilizada con para mejorar la compresión de la cirugía hepatobiliar en los estudiantes de medicina. Entre septiembre de 2022 y enero de 2024 realizamos un estudio prospectivo entre los alumnos de medicina de 4º curso. Se implementó una nueva metodología docente basada en innovaciones tecnológicas centradas en 3D de última generación. Mediante una encuesta se valoraron índices de satisfacción, utilidad, mejora, implementación, compresión y motivación. Un total de 46 alumnos contestaron al cuestionario. Un 95,7% estaban de acuerdo con que los modelos virtuales 3D y la realidad virtual favorecen a mostrar un mayor interés por la clase sin ninguna respuesta desfavorable al respecto. Un 95,7% coinciden con que la utilización de modelos impresos en 3D deberían tener más presencia en las clases de cirugía. Un 97,8% estaban de acuerdo en que los vídeos quirúrgicos asistidos por reconstrucciones 3D deberían tener más presencia en las aulas. Los resultados de este estudio respaldan la efectividad y la aceptación de la metodología docente basada en tecnología 3D en la enseñanza de la anatomía quirúrgica hepática.

Postoperative complications after perihilar cholangiocarcinoma surgical procedure are still very high. The implementation of a multimodal prehabilitation program could improve these outcomes. Based on our experience and that of the literature in hepatobiliary and pancreatic surgery, we propose a protocol to promote its implementation. First, we performed a retrospective analysis of the implementation feasibility of a multimodal prehabilitation program in patients’ candidates for elective perihilar cholangiocarcinoma surgery in our center. Second, we conducted a literature search of publications in PubMed until December 2022. Relevant data about hepato-pancreato-biliary surgery and prehabilitation programs in features and postoperative outcomes was analyzed. Since October 2020, 11 patients were evaluated for prehabilitation in our hospital. Two of them could not be resected intraoperatively due to disease extension. The median hospital stay was 10 days (iqr, 7–11). There were no major complications and 1 patient died. Of a total of 17 articles related to prehabilitation in hepato-biliary-pancreatic surgery, no reports focusing exclusively on perihilar cholangiocarcinoma were found. Six of the studies had nutritional therapies in addition to physical interventions, and 12 studies used home-based exercise therapy. Based on our experience and the data obtained from other studies, a prehabilitation program could be useful to improve perioperative physical and mental fitness in patients’ candidates for elective perihilar cholangiocarcinoma surgery. However, more well-designed studies are needed to allow us to obtain more evidence.