The AFP model, originally developed to refine biological selection for liver transplantation, integrates tumor size, number, and serum AFP level. It was shown to be superior to the Milan criteria for predicting hepatocellular carcinoma (HCC) after liver transplantation. Although widely validated in the transplant setting, its prognostic value after hepatic resection for HCC remains insufficiently defined. This study aimed to assess the performance of the AFP score in predicting recurrence and survival after curative hepatectomy in a contemporary French multicenter cohort. We retrospectively analyzed consecutive adults undergoing curative-intent liver resection for pathologically confirmed HCC across five high-volume French hepatopancreatobiliary centers between 2012 and 2021. Patients were classified according to AFP score (≤ 2 vs. > 2). Survival outcomes were estimated by using Kaplan–Meier methods, and prognostic factors were evaluated by using univariable and multivariable Cox regression analyses. Among 424 patients, median overall survival (OS) was 112.8 months, and median recurrence-free survival (RFS) was 37.1 months. In univariable analysis, the AFP score was significantly associated with OS (hazard ratio [HR] 1.22, p = 0.001) and RFS (HR 1.25, p < 0.001). In multivariable analysis, the AFP score remained independently predictive of recurrence (HR 1.18, p = 0.004). Patients with AFP score > 2 had significantly lower 24-month RFS compared with those with a score ≤ 2 (log-rank p = 0.0005). In this large French multicenter cohort, the AFP model, originally validated in transplantation, retains strong prognostic value after hepatectomy, independently predicting recurrence. Integrating the AFP model into preoperative assessment may improve biological risk stratification and guide postoperative surveillance and future neoadjuvant and adjuvant strategies.

BACKGROUND:Management of low locally advanced rectal cancer (LARC) requires balancing oncologic radicality, sphincter preservation, postoperative function, and long-term stoma acceptability. These challenges are amplified in settings where socioeconomic and cultural factors influence treatment decisions. This study aimed to provide a descriptive comparison of surgical and reconstructive pathways for LARC in France and Morocco. METHODS:This retrospective bicentric study included patients operated on between January 2017 and December 2024 for low LARC (cT3/T4 and/or node-positive adenocarcinoma within 5 cm of the anal verge). Outcomes were compared between Tours University Hospital, France (LARC-Fr), and the National Institute of Oncology, Rabat, Morocco (LARC-Mo). RESULTS:A total of 224 patients were included (80 LARC-Fr; 144 LARC-Mo). French patients were older (68 vs 57 years, p < 0.001) and had higher ASA III-IV scores (26.3% vs 2.1%, p < 0.001), whereas cT4 tumors were more frequent in Morocco (22.9% vs 7.5%, p = 0.003). Sphincter-preserving procedures, including intersphincteric resection (35.0% vs 0%, p < 0.001) and TaTME (35.0% vs 2.8%, p < 0.001), were more common in France, while abdominoperineal resection (APR) predominated in Morocco (79.2% vs 48.8%, p < 0.001). Among Moroccan patients with a definitive stoma, pseudocontinent perineal colostomy (PCPC) was performed in 64.1%. Major postoperative morbidity and reoperation rates did not differ significantly between cohorts. Complete mesorectal excision and R1 resection rates did not differ significantly. Three-year disease-free survival was 74.5% versus 73.2% (p = 0.075), and overall survival was 85.0% versus 71.9% (p = 0.279), respectively. CONCLUSIONS:This bicentric retrospective study describes distinct surgical and reconstructive pathways for low rectal cancer in France and Morocco. In the Moroccan cohort, PCPC was used after abdominoperineal resection as an alternative to a conventional permanent abdominal colostomy when sphincter preservation was not considered appropriate.

In this study, we aim to assess the impact of tumor height on surgical strategy, oncological outcomes, and long-term function in locally advanced rectal cancer. This retrospective cohort study included patients with cT3–T4 and/or N+ rectal cancer treated between 2017 and 2024. Tumors were classified as low locally advanced rectal cancer (LARC; 0 to < 5 cm) or middle locally advanced rectal cancer (MARC; ≥ 5 to < 10 cm). All patients underwent total mesorectal excision (TME) following multimodal therapy. Outcomes included perioperative variables, overall survival (OS), disease-free survival (DFS), and functional results assessed using Wexner, low anterior resection syndrome (LARS), the 36-Item Short-Form health survey (SF-36), and Five-Item International Index of Erectile Function (IIEF-5) scores. Predictors of permanent stoma were analyzed using multivariable regression. A total of 164 patients were included (MARC n = 84; LARC n = 80). Sphincter-sacrificing procedures were significantly more frequent in LARC (abdominoperineal resection [APR]: 48.8

3589 Background: Following the TRANSMET trial that demonstrated an overall survival (OS) benefit of liver transplantation (LT) over chemotherapy (CT) alone for selected patients with permanently unresectable colorectal liver metastases (uCRLM), the program of LT has continued in France with the same eligibility criteria, independent validation and graft allocation policy. We assessed the real-world oncological outcomes and prognostic factors for post-LT recurrence-free survival (RFS) in the whole cohort. Methods: This nation-wide analysis pooled both patients transplanted in TransMet (Trial cohort) and those after trial closure (Extension cohort). OS and RFS were evaluated in each cohort. Multivariable Cox models for RFS using sensitivity analyses including forced cohort adjustment and bootstrap resampling were performed. Results: A total of 87 patients underwent LT (37 Trial cohort; 50 Extension cohort). Baseline characteristics at CRLM diagnosis were comparable. At LT, patients in the Extension cohort received significantly fewer CT cycles (≥24 cycles, 16% vs 41%, p=0.01) and showed higher rate of partial response (94% vs 57%, p < 0.001) after first-line CT. At time of LT, tumor burden, RECIST status and tumor markers were similar. Median follow-up was shorter in the Extension cohort (16 vs 57 months). No significant differences in OS and RFS were observed between extension and trial cohorts (30-months OS 89% vs 81%; 30-months RFS 47% vs 39%, respectively). In univariable analysis, risk factors of RFS included ≥2 CT lines, ≥24 CT cycles before LT, CEA at LT > 5 ng/mL, progression on CT and interval from primary tumor surgery >2 years. In multivariable Cox analysis, ≥2 lines or >24 cycles before LT (HR 2.90, 95% CI 1.32–6.36; p<0.01) and CEA at LT >5 ng/mL (HR 2.26, 95% CI 1.18–4.33; p=0.01) remained independently associated with RFS, adjusted on interval from primary tumor surgery. Bootstrap resampling (2,000 iterations) highlighted these results in 82% and 67% of models, respectively. Conclusions: LT for uCRLM gives good and reproducible oncological outcomes across trial and extension cohorts. This exploratory analysis supports that RFS is impaired by a prolonged pre-transplant chemotherapy (≥ 2 lines or ≥ 24 cycles) and improved by a good biological response (normalization of CEA), supporting considering LT in a multidisciplinary setting as soon as definitive unresectability is established.

BACKGROUND & AIMS:Liver transplantation (LT) is indicated for liver complications related to hepatitis B virus (HBV) infection: acute liver failure (ALF), decompensated cirrhosis or hepatocellular carcinoma (HCC). The present study aimed to describe and evaluate patient survival after LT for HBV-related disease in France and identify the factors influencing survival. METHODS:The present retrospective cohort study based on medical record information included all adult patients transplanted with positive HBsAg (+/- coinfection with Hepatitis D virus (HDV)) between January 1, 2005 and December 31, 2023 in all French LT centres. RESULTS:The study population consisted of 1083 patients, the majority of whom were men (81.5%) with a median [IQR] age at LT listing of 52.8 [42.5-59.8] years. Indications for LT were HBV-related HCC (47.2%), HBV-related cirrhosis (28.5%), HDV-related cirrhosis (11.2%), HBV-related ALF (10.5%), HDV-related HCC (1.4%) and other (0.7%). Median [IQR] post-LT follow-up was 6.0 [2.2-11.1] years. Patient survival at 1, 5, 10 and 15 years after LT was 91.6%, 80.1%, 71.8% and 63.6% respectively. Multivariate analysis showed that independent significant prognostic factors were age at LT (HR: 1.030; 95CI: 1.019-1.042; p < 0.0001) and the pre-LT nucleos(t)ides analogue (NUC) regimen: in comparison to tenofovir, the use of entecavir alone (HR: 1.735; 95CI: 1.312-2.295; p < 0.0001) or another NUC or combination therapy (HR: 1.471; 95CI: 1.059-2.043; p = 0.021) were associated with decreased survival. CONCLUSIONS:Survival after LT for HBV-related liver disease is good. NUC type prior to LT seems to be associated with patient survival.

BACKGROUND & AIMS:We compared multibipolar radiofrequency ablation (mbpRFA) with open liver resection (OLR) or laparoscopic liver resection (LLR) in patients with HCCs within Milan. METHODS:This multicenter cohort study included patients treated by mbpRFA, OLR or LLR for HCC within the Milan Criteria, developed on advanced fibrosis in nine French centres between 2008 and 2018. Adjustments on HCC size/number, gender, age, ASA, HCV, HBV, metabolic syndrome, chronic alcohol intake, MELD score, serum AFP level, APRI score, cirrhosis, significant portal hypertension and HCC localization were performed using multivariable regressions with centre-robust variance and propensity score-based matching (3:1 nearest-neighbour with calliper < 0.1; effective ratios 2.18:1 and 2.43:1). RESULTS:1040 patients were included (median age: 64 years; male 82.9%), with 606, 266 and 168 treated by mbpRFA, LLR and OLR. Most HCCs were solitary (84.8%) and on cirrhosis (89.2%). In months, the follow-up was 50.2 (95% CI: 45.3, 54.3), 43.3 (95% CI: 40.0, 48.6) and 47.4 (95% CI: 40.8, 58.7) for mbpRFA, LLR and OLR patients. After matching, OLR patients had similar overall survival (OS) (HR = 1.05 [CI 95% = 0.65, 1.69], p = 0.853), transplant-free survival (TFS) (HR = 0.91 [CI 95% = 0.56, 1.47]; p = 0.690) or recurrence-free survival (RFS) (HR = 0.99 [CI 95% = 0.69, 1.43]; p = 0.968) compared to mbpRFA patients but with more severe adverse events (RR = 2.58 [CI 95% = 1.16, 5.71]; p = 0.02) and mortality (RR = 4.51 [CI 95% = 1.16, 17.59]; p = 0.03). After matching, LLR patients had better OS (HR = 0.57 [CI 95% = 0.38, 0.88], p = 0.01) but similar TFS (HR = 0.77 [CI 95% = 0.55, 1.1]; p = 0.152) and more severe adverse events (RR = 2.61 [CI 95% = 1.15, 5.96]; p = 0.022) compared to mbpRFA patients. LLR patients had a better RFS (HR = 0.7 [CI 95% = 0.53, 0.91]; p = 0.009) than mbpRFA patients. When distant-only recurrences were considered in the mbpRFA patients, there was no significant difference in RFS (p = 0.087). The LLR survival benefit was consistent across pre-specified subgroups, with no interaction surviving correction for multiple testing. CONCLUSIONS:Minimally invasive modalities (LLR or mbpRFA) should be prioritized when treating early HCC. LLR maximizes oncological outcomes, but mbpRFA maintains optimal TFS with less morbidity.

BACKGROUND:Pancreatic resection (PR) may require portal/superior mesenteric vein resection (VR). Outcomes of minimally invasive PR (MIPR) with VR are poorly studied. METHODS:Multicentric retrospective cohort of MI pancreatoduodenectomy (MIPD) and left pancreatectomy (MILP) with or without VR between 2010 and 2021. Propensity score matching analysis stratified on age, sex, BMI, pancreas texture, tumor type, ASA score, conversion and surgical approach was performed. RESULTS:After matching, 234 MIPD were included, 78 (33.3%) with and 156 (66.7%) without VR. VR had greater blood loss (400 vs 300 mL; p = 0.033) and operative time (471 vs 430 min; p = 0.012). VR had 10.3% mortality compared to 4.5% (p = 0.097), similar severe morbidity (30.8% vs 37.8%: p = 0.313) and R0 resection rate (84.9% vs 90.8%: p = 0.252). After matching, 275 MILP, 25 (9%) with and 250 (91%) without VR were compared. VR had greater blood loss (350 vs 150mL; p = 0.019) and operative time (300 vs 240 min; p = 0.005). VR had 8% mortality versus 2% (p = 0.126), 19.2% severe morbidity versus 8% (p = 0.274) and lower R0 resection rate (58.3% vs 94.9%; p <0.001). CONCLUSION:MIPR with VR has non-significant increased postoperative mortality, lower R0 resection rate and therefore cannot be considered as a standard of care.

Esophageal perforation is a rare but life-threatening condition associated with high morbidity and mortality. Optimal management remains controversial, particularly regarding the indications for conservative, endoscopic, and surgical strategies. We conducted a retrospective single-center cohort study including adult patients treated for esophageal perforation between January 2018 and November 2023. Patients were categorized into conservative management (CM) or surgical management (SM). Clinical presentation, etiology, treatment modalities, complications, and mortality were analyzed. A subgroup analysis compared esophageal preservation with esophagectomy within the surgical group. Fifty-eight patients were included (CM: n = 30; SM: n = 28). Patients in the SM group presented with significantly greater severity, including higher rates of mediastinitis (96.4

BACKGROUND:A significant proportion of patients presenting a primary sclerosing cholangitis (PSC) will require liver transplantation (LT). The present study aimed to investigate graft loss and patient death in a large cohort of patients. METHODS:We conducted a nationwide multicenter retrospective study including all adult patients transplanted for PSC in France From 1985 to 2019. RESULTS:Were included 571 patients; median follow-up after LT was 89.0 months (IQR, 43.0-151.0). Patient survival at 5, 10 and 20 years after LT was 88.2%, 81.2% and 62.6%. After exclusion of patients who died during the first month after LT, 37 patients (6.6%) died during the first 2 years and the main cause was malignancies (n = 15, 40.5%, including 12 cases of recurrent cholangiocellular carcinoma). After 2 years, 90 patients (17.2%) died; the two main causes were malignancies (n = 36, 40.0%, including 13 cases of colorectal cancer) and sepsis (n = 23, 25.6%, of which 7 were related to recurrent PSC). Graft survival at 5, 10 and 20 years was 89.5%,78.7% and 62.7%. Independent factors associated with late patient death (after 2 years) were an older age at LT, a bilio-digestive anastomosis and the use of preventive UDCA; independent factors associated with late graft loss were recurrent PSC, cellular rejection, a younger age at LT, and the use of tacrolimus (protective). CONCLUSIONS:Our results emphasise that the prognosis after LT for PSC could be improved by better detection of cholangiocellular carcinoma before LT, and colorectal cancer after LT.

The expansion of minimally invasive surgery has transformed surgical practice and training worldwide. However, operative exposure to laparoscopic and open procedures may vary across healthcare systems. Comparative international data on operative autonomy and procedural experience during surgical residency remain limited. This study aimed to compare operative exposure, autonomy, and trainee perceptions regarding open and laparoscopic surgery among surgical trainees at selected centers in France and Morocco. A multicenter cross-sectional survey was conducted among surgical trainees at academic centers in France and Morocco. Participants were stratified by postgraduate year (PGY 1–8). Self-reported operative exposure and autonomy were assessed for common general surgical procedures (appendectomy, cholecystectomy, and inguinal hernia repair) and complex colorectal procedures (colectomy and proctectomy) performed using open and laparoscopic approaches. Trainee perceptions of preparedness for minimally invasive surgery and the value of prior training in open surgery were also evaluated. Comparisons were made according to country and level of training. A total of 131 trainees participated, including 67 from Morocco and 64 from France. Trainees at French centers reported significantly greater exposure to laparoscopic procedures across training levels (p < 0.001), whereas trainees at Moroccan centers reported greater exposure to open appendectomy, inguinal hernia repair, and proctectomy (p < 0.001). Operative autonomy increased with training seniority in both groups, although trainees at French centers reported greater autonomy in laparoscopic procedures. Trainees at Moroccan centers were significantly more likely to consider prior training in open surgery necessary before performing laparoscopic procedures (p < 0.01). These findings support context-adapted curricula that preserve competence in open surgery while expanding access to structured, supervised training in minimally invasive surgery.

BACKGROUND:Robotic adrenalectomy (RA) is increasingly adopted, but its clinical value compared with laparoscopic adrenalectomy (LA) remains unclear. We assessed perioperative outcomes and the learning curve of RA. METHODS:A bicentric retrospective study included 228 patients who underwent adrenalectomy between 2013 and 2023 (97 RA, 131 LA). Primary outcomes were intra- and postoperative complications (Clavien-Dindo, Comprehensive Complication Index, CCI). Secondary outcomes included operative time and length of stay (LOS). Subgroup analysis evaluated tumors ≥ 6 cm. RA learning curve was assessed with cumulative sum (CUSUM) analysis. RESULTS:Patients in the RA group had higher ASA scores, more prior abdominal surgery, and larger tumors. Overall complication rates were similar (RA 18.6% vs. LA 17.6%, p = 0.846). RA was independently associated with shorter LOS (OR 0.48; 95% CI 0.26-0.84; p = 0.012). In tumors ≥ 6 cm, RA reduced postoperative complications (5.3% vs. 35.3%, p = 0.037). CUSUM analysis showed earlier improvements in operative time (after 25 cases) and later reductions in morbidity (after ∼ 45 cases). CONCLUSIONS:RA is a safe alternative to LA even in complex patients. It shortens LOS overall and improves outcomes in large adrenal tumors. CUSUM analysis highlights a progressive but safe learning curve, supporting the integration of RA into endocrine surgical practice.