Laparoscopic liver surgery offers several benefits, yet the adoption of laparoscopic right hemihepatectomy (RH) is slow, owing to its high degree of technical complexity. It is uncertain whether the general benefits of laparoscopy also extend to RH. This study evaluates perioperative outcomes of laparoscopic vs open RH, and illustrates differences in laparoscopic RH and left hemihepatectomy (LH) within the international, multicentre, double-blinded ORANGE-II-PLUS randomized trial. Patients were randomly assigned to open (n = 166) or laparoscopic hemihepatectomy (n = 166). The present post-hoc subgroup analysis compares perioperative and oncological outcomes of laparoscopic RH (n = 105) vs open RH (n = 108). In addition, interaction between surgical approach (open or laparoscopic) and hemihepatectomy laterality (RH; n = 213 vs LH; n = 119) was assessed. There was a higher proportion of malignancy, including more colorectal liver metastases, and more preoperative portal vein embolization in patients undergoing RH compared to LH, other characteristics were well-balanced. The laparoscopic approach was associated with shorter time to functional recovery compared to open surgery for RH (median 5 vs 5 days, p = .004) and shorter length of hospital stay (median 5 vs 6 days, p = .014). Except for longer operating times in laparoscopy (332 vs 263 min, p < .001), no differences were found in other perioperative and oncological outcomes between laparoscopic and open RH. For all outcomes, interaction testing between surgical approach and laterality did not reach significance, suggesting that approach did not affect RH and LH differently. Though patients requiring laparoscopic RH needed longer operating time (332 vs 225 min) and time to functional recovery (median 5 vs 3 days) than patients requiring laparoscopic LH. Patients undergoing RH showed modest, population-level, benefits from a laparoscopic approach with regard to time to functional recovery and hospital length of stay, despite higher technical complexity and a more pronounced postoperative impact on the patient. Interaction testing between RH and LH did not reach significance, suggesting the effect of the approach on outcomes were consistent regardless of resection laterality. These results support the implementation of the laparoscopic approach for RH if surgeons are experienced. NCT01441856.

Minimally invasive liver surgery has become widely accepted as a safe and effective approach, especially with experienced surgeons. Robotic hepatectomy may offer significant benefits in challenging procedures like caudate lobe resection. The caudate lobe’s intricate anatomy and deep-seated location make its resection particularly challenging, with limited reports on minimally invasive techniques. The aim of this study was to assess the feasibility and safety of robotic isolated complete caudectomy and to provide a detailed description of the different technical approaches available. This retrospective multicenter study was conducted across eight experienced hepatobiliary robotic surgery centers between June 2020 and March 2024. All patients who underwent elective RICC during this period were included. Data were prospectively collected and retrospectively analyzed, focusing on demographics, intraoperative variables, postoperative outcomes, and histopathological results. The primary outcome was the feasibility and safety of the robotic approach. The study included 42 patients. The median (IQR) operative time was 180 (125–245) min, with a median estimated blood loss of 30 (0–100) ml. There were no conversions to open surgery and only one severe complication (Clavien-Dindo ≥ 3) occurred. No postoperative mortality was observed, and all resections for malignant lesions achieved R0 margins. The median time to flatus was 1 (1–1) day, time to solid diet was 1 (1–2) days, and the median length of stay was 3 (2–4) days. RICC is a feasible and safe procedure, demonstrating significant benefits in operative efficiency and patient recovery. However, further research with larger, prospective multicenter studies is necessary to confirm these findings and assess long-term outcomes.

Background:Health-related quality of life (HRQoL) has become a critical factor in determining the benefits of new surgical approaches on patients. The ORANGE II PLUS randomised trial compared laparoscopic (LH) and open (OH) hemihepatectomy in an international multicentre randomised controlled setting, with HRQoL as a secondary outcome. The aim of this study was to perform an in-depth analysis of the HRQoL outcomes. Methods:Between October 2013 and January 2019, 352 patients scheduled for hemihepatectomy, were randomly assigned to either LH or OH in a 1:1-ratio in 16 European centres. HRQoL was assessed using the EORTC-QLQ-C30 and QLQ-LMC21 modules, at baseline, hospital discharge, and at 10-days, 3-, 6-, and 12-months after discharge. Differences in functioning- and five selected symptom scales were compared between LH and OH over the cumulative periods from discharge to 3 months as well as to 12 months using a multivariable adjusted linear mixed regression model. The study was registered at ClinicalTrials.gov (NCT01441856). Findings:The modified intention-to-treat analysis included 332 patients (166 LH and 166 OH), with 40% female in LH and 42% female in OH. 1546 questionnaires (81% of maximum) were obtained. Cumulatively over the period from discharge to 3 months postoperatively, patients in the laparoscopic group reported better physical (difference 4.20 points; 95% CI 1.07-7.34) and social functioning (5.95 points; 95% CI 1.65-10.26), and lower pain (-6.41 points, 95% CI -10.01 to -2.82) and appetite loss (-7.29 points, 95% CI -11.59 to -2.99), compared to the OH group. Similar clinically relevant, but slightly attenuated, differences were reported over the cumulative period from discharge to 12 months after surgery. The largest difference was observed at 10 days after surgery. Interpretation:In this international randomised trial evaluating HRQoL, LH demonstrated better physical and social functioning, and less pain and appetite loss, compared to OH. These findings support the preferential use of the laparoscopic approach for hemihepatectomy in experienced centres. Funding:Maastricht University Medical Centre+, University Hospital RWTH Aachen, Cancer Research UK 12/048, European Association of Endoscopic Surgery, participating centres.

Gallstone disease is common after gastric surgery and especially after weight loss from bariatric surgery. In patients with normal gastroduodenal anatomy, treatment of common bile duct stones (CBS) generally consists of, endoscopic retrograde cholangiopancreaticography (ERCP) and endoscopic sphincterotomy (ES), followed by cholecystectomy in a second stage. However, after gastric surgery the papilla may not be easily accessible endoscopically. The aim of our study was to evaluate the therapeutic success of single-stage laparoscopic cholecystectomy and common bile duct exploration (LCBDE) after previous gastric surgery. In this observational cohort study, all LCBDE in patients with previous gastric surgery between January 2014 and July 2022 were retrospectively reviewed. Gastric surgery consisted of Roux-en-Y gastric bypass, BII subtotal gastrectomy, total gastrectomy and subtotal gastrectomy with Roux-en-Y reconstruction. Outcomes of interest consisted of successful duct clearance, postoperative adverse events and CBS recurrence. Forty-four patients (M/F: 22/22) underwent LCBDE after previous gastric surgery, in which simultaneous cholecystectomy was performed in 38 cases. Median (range) age 68 (25–90) years. Presence of CBS was confirmed in 38 patients (85

Laparoscopic hemihepatectomy (LH) has favorable short-term outcomes compared with open hemihepatectomy (OH), including shorter hospital stay. An in-depth healthcare utilization and cost-effectiveness analysis of the international multicenter ORANGE II PLUS randomized controlled trial comparing LH and OH was performed. Patients were randomly assigned to LH or OH in 16 European centers from October 2013 to January 2019. Costs were determined as a product of unit costs using patient-level, clinician-reported resource utilization up to 90 days. Item-specific resource use per country was presented. The measure of effect was quality-adjusted life year (QALY). Cost and effect differences were compared between treatment arms using nonparametric bootstrapping, from a Dutch healthcare cost perspective. A cost-effectiveness analysis was performed to establish the incremental cost-effectiveness ratio (ICER), i.e., costs per QALY gained, for LH compared with OH 1 year postoperatively. Among 332 patients randomized to LH (n = 166) and OH (n = 166), intraoperative costs were higher for LH (LH 13,208 € versus OH 9437 €), while postoperative costs were lower for LH (LH 5774 € versus OH 7703 €). Longer operative time and greater instrument use contributed to higher intraoperative costs, while shorter hospital stays contributed to lower postoperative costs. Mean overall costs per patient were higher in LH (LH 18,982 € versus OH 17,141 €). The QALYs gained over 1 year postoperative were mean (standard deviation [SD]) 0.834 (0.218) for LH and mean 0.795 (0.237) for OH. The ICER was 36,677 € per additional QALY gained, and uncertainty analyses showed that LH had a 77

OBJECTIVE:To compare postoperative outcomes after extended robot-assisted left pancreatectomy (e-RLP) and extended laparoscopic left pancreatectomy (e-LLP). SUMMARY BACKGROUND DATA:The implementation of RLP is increasing worldwide with expanding indications, resulting in more extended resections. However, the use of e-RLP has not been investigated before. METHODS:International study including consecutive patients after e-RLP and e-LLP for all indications in 19 European countries (2012-2022). Extended resection was defined according to the ISGPS definition. Propensity score matching (PSM) was performed in a 1:1 ratio with a caliper width of 0.1. Primary endpoint was major morbidity (Clavien-Dindo grade ≥III complications). RESULTS:Overall, 514 patients were included from 72 centers (152 e-RLPs; 362 e-LLPs). Before PSM, e-RLP patients had more tail tumors (69.4% vs 50.0%, P=0.001), vascular involvement (30.3% vs 16.3%, P<0.001) and >2 additional organ resections (28.5% vs 10.7%, P<0.001), with comparable major morbidity rates (27.0% vs 27.0%, P=0.991) and a lower conversion rate (15.1% vs 23.5%, P=0.033), compared to e-LLP. After PSM, 119 e-RLP patients were matched to 119 e-LLP patients. No significant differences were observed in major morbidity (23.5% vs 26.5%, P=0.599), blood loss (200 vs 150 mL, P=0.835), conversion rate (16.0% vs 20.0%, P=0.422), 30-day/in-hospital mortality (1.7% vs 3.4%, P=0.408), and hospital stay (median 7 vs 7 days, P=0.906). E-RLP had longer operative times (median 277 vs 228 min, P<0.001). CONCLUSIONS:This pan-European cohort study found no significant differences in the outcomes among matched patients undergoing e-RLP and e-LLP, although e-RLP was associated with a longer operative time. The robot-assisted approach is used for more extensive resections with a comparable major morbidity rate compared to laparoscopy.

PURPOSE To compare outcomes after laparoscopic versus open major liver resection (hemihepatectomy) mainly for primary or metastatic cancer. The primary outcome measure was time to functional recovery. Secondary outcomes included morbidity, quality of life (QoL), and for those with cancer, resection margin status and time to adjuvant systemic therapy. PATIENTS AND METHODS This was a multicenter, randomized controlled, patient-blinded, superiority trial on adult patients undergoing hemihepatectomy. Patients were recruited from 16 hospitals in Europe between November 2013 and December 2018. RESULTS Of the 352 randomly assigned patients, 332 patients (94.3%) underwent surgery (laparoscopic, n = 166 and open, n = 166) and comprised the analysis population. The median time to functional recovery was 4 days (IQR, 3-5; range, 1-30) for laparoscopic hemihepatectomy versus 5 days (IQR, 4-6; range, 1-33) for open hemihepatectomy (difference, -17.5% [96% CI, -25.6 to -8.4]; P < .001). There was no difference in major complications (laparoscopic 24/166 [14.5%] v open 28/166 [16.9%]; odds ratio [OR], 0.84; P = .58). Regarding QoL, both global health status (difference, 3.2 points; P < .001) and body image (difference, 0.9 points; P < .001) scored significantly higher in the laparoscopic group. For the 281 (84.6%) patients with cancer, R0 resection margin status was similar (laparoscopic 106 [77.9%] v open 122 patients [84.1%], OR, 0.60; P = .14) with a shorter time to adjuvant systemic therapy in the laparoscopic group (46.5 days v 62.8 days, hazard ratio, 2.20; P = .009). CONCLUSION Among patients undergoing hemihepatectomy, the laparoscopic approach resulted in a shorter time to functional recovery compared with open surgery. In addition, it was associated with a better QoL, and in patients with cancer, a shorter time to adjuvant systemic therapy with no adverse impact on cancer outcomes observed.

BACKGROUND:Accidental ingestion of foreign bodies is a common problem in children. Fortunately, the gastrointestinal tract is quite resilient to foreign bodies. On the other hand, the ingestion of magnets can result in enormous morbidity. Because of their natural tendency to firmly adhere they can cause intestinal obstruction, pressure necrosis, fistula formation or perforation. With this case report, we aim to raise awareness of the risks that these magnets pose to children.METHODS:We describe a case of intestinal perforation caused by the separate ingestion of multiple magnets from a children's toy (buckyballs, Neodymium spheres) by a two-year-old boy. A search in the Pubmed database showed some publications and varied management guidelines.RESULTS:The boy was treated with an exploratory laparoscopy converted to a mini-laparotomy. We removed the four magnets through separate enterotomies. Postoperative recovery was uneventful. The boy was discharged on a postoperative day five and had no complications at three months follow-ups.CONCLUSION:Accidental ingestion of multiple magnets is rare but can create a life-threatening situation in children. If the magnets are still in the stomach, endoscopic retrieval is needed. If they are beyond the stomach, in asymptomatic cases close clinical and radiographic vigilance is mandatory. When symptomatic we advise urgent removal. If treated on time, the surgical outcome is good and fast recovery is expected.

This article has been removed: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/policies/article-withdrawal). This article has been removed at the request of the Authors. The data in the article is restricted by publication regulations and the authors did not have permission to publish the data. The authors apologize for any inconvenience this may cause. REMOVED: Patient reported outcomes after laparoscopic versus open hemihepatectomy within an enhanced recovery program, the ORANGE-II-PLUS Randomized Clinical trial: A Quality of Life and Body image analysisEuropean Journal of Surgical OncologyVol. 49Issue 2PreviewThis article has been removed: please see Elsevier Policy on Article Withdrawal ( https://www.elsevier.com/locate/withdrawalpolicy ). Full-Text PDF

Introduction: Despite the large impact on Health-related Quality-of-Life (HRQoL) of major hepatectomy, the possible benefits of minimal invasive techniques on short and long-term HRQoL after major hepatectomy are unclear. The international multicenter ORANGE-II-PLUS trial compared laparoscopic (LH) and open hemihepatectomy (OH) aiming to show a reduction in Time to Functional Recovery after LH. This substudy assesses improved HRQoL after LH compared to OH in a randomized controlled setting. Methods: In the ORANGE-II-PLUS trial, patients were randomly assigned to either open or laparoscopic hemihepatectomy in 1:1 ratio. HRQoL was assessed using EORTC-QLQ-C30 with the added liver disease specific QLQ-LMC21 module. For further exploration, body image was assessed using a validated body image and cosmesis questionnaire. Data were collected at baseline and discharge, and at 10-days, 3 months, 6 months and 1 year after discharge. Global Health Status (GHS) was selected as primary HRQoL endpoint. To detect a 10 point difference in GHS after LH, with a 2-sided α=0.05 and 90% power; 172 patients were required, which amply fits within the sample size of the ORANGE-II-PLUS trial. All differences over time were compared using a linear mixed model. Results: 352 eligible patients were randomly assigned to LH (n=177) or OH (n=175), from October 2013 to January 2019. Excluding drop-outs, ITT-analysis included 332 patients (LH n=166 vs OH n=166). HRQoL Data are analyzed in the nearby future. Conclusion: An ITT-analysis of HRQoL outcomes will be performed around August 25th 2021. Results will be available as late-breaking abstract before start of IHPBA 2022.

Abstract Background Neuroendocrine tumors (NETs) are a group of biologically and clinically heterogeneous neoplasms predominantly found in the gastrointestinal and bronchopulmonary tractus. Despite a rising incidence, implementation of evidence‐based standardized care for this heterogenous group remains challenging. The European Neuroendocrine Tumor Society regularly reviews guidelines regarding diagnostic and treatment strategies for NETs. The aim of this study is to shed light on the care of patients with a NET in Belgian Limburg, to provide data as a basis for future studies and to check whether data and results are according to consensus guidelines and outcomes described in literature. Methods Our study concerned a detailed observational data collection of two large Belgian hospitals (Jessa Hospital Hasselt and Hospital Oost‐Limburg Genk) with special interest in patient profile, quality of pathology reports, use of diagnostic imaging, and overall survival. Data on 188 patients were assembled between January 2010 and December 2014 with follow‐up until June 2016 (median follow‐up: 33.6 months). Results Fifty percent of patients were male. NETs were located mainly in the digestive tract (63.8%) and lung (20.2%). Appendiceal NETs were diagnosed at a significantly younger age than other tumors (41.3 vs. 64.0 years). Overall, a mean pathology report quality score of 3.0/5 was observed with the highest scores for small bowel NETs. Diagnostic and nuclear imaging was performed in 74.5% and 29.8% of cases, respectively. Seventy‐four percent of the population survived until the end of the observation period with highest survival rates for appendiceal and small bowel NETs. Conclusion Overall, epidemiological results were comparable with findings in the literature. Gastrointestinal NETs met most of the requirements of qualitative pathology reporting and diagnostic imaging as listed in the European Neuroendocrine Tumor Society consensus guidelines. However, consensus with regard to bronchopulmonary NETs is still scarce and remains an objective for future research. Moreover, discussing treatment strategies in specialized multidisciplinary tumor boards would facilitate regional care.

INTRODUCTION:Postoperative complications are associated with prolonged hospital stay and a rise in costs of treatment. The Comprehensive Complication Index (CCI) was developed as a scoring system that does not only take the most severe complication into account but all complications after surgery. Our aim was to compare the Clavien-Dindo scoring system with the CCI in predicting length of hospital stay (LOHS) and in-hospital costs after colorectal resections. METHODS:Complications occurring after surgical procedures, performed between October 2012 and September 2013, were prospectively recorded. During this period 164 patients developed complication(s). Only patients that underwent a colorectal resection were included. Multivariable linear regression analysis was performed to find independent predictors of in-hospital costs and LOHS. RESULTS:64 patients (age (range): 69 (10-91) years, M/F: 36/28) were retained. 46 (71.9%) patients had a Clavien-Dindo score ≥ IIIb. Median (IQR) CCI was 40 (30.2-53.9). Mean (±SD) in-hospitals costs for all patients were €12,920 ± €10,229. The adjusted difference (95% CI, p-value) in in-hospital costs for minor and major (Clavien-Dindo ≥ IIIb) complications was 10,021 (€4283 to €15,759, p = 0.001). A 10 point increase in CCI increased in-hospital costs by €2040. Multivariable analysis retained CCI > 40 as the only independent risk factor for increased in-hospital costs (Standard Beta Coeffic (p-value): 8063 (p = 0.022). CONCLUSION:CCI is a better predictor of in-hospital costs than Clavien-Dindo score to classify complications after colorectal resections, as it captures all complications. Further research is warranted to extrapolate our findings to other sub-specialities of surgery.

Laparoscopic resection of the hepatic caudate lobe (LRCL) requires a high level of expertise due to its challenging anatomical area. Only case reports, case series, and single-center cohort studies have been published. The aim of this study was to assess the safety and feasibility of this laparoscopic procedure. A multicenter retrospective cohort study including all patients who underwent LRCL in 4 high-volume hepatobiliary units between January 2000 and May 2018 was performed. Perioperative, postoperative, and survival outcomes were assessed. Postoperative morbidity was stratified according to the Clavien-Dindo classification with severe complications defined by grade III or more. The Kaplan-Meier method was used for survival analysis. A total of 32 patients were included, including 22 (68.8%) with colorectal liver metastasis (CRLM), one (3.1%) with cholangiocarcinoma, four (12.5%) with other malignancies, and five (15.6%) with symptomatic benign lesions. Simultaneous colorectal and/or additional liver resection was performed in 20 (62.5%) patients. The median (IQR) operative time was 155 (121–280) minutes, blood loss was 100 (50–275) ml, conversion rate was 9.4% (n = 3), severe complications were observed in 2 patients (6.3%), and median (range) length of hospital stay was 3 [1–39] days. No 90-day postoperative mortality was noticed. The median (IQR) follow-up for the CRLM group was 14 [10–23] months. Five-year overall survival rate was 82% in this subgroup. Small interinstitutional differences were observed without major impact on surgical outcomes. LRCL is safe and feasible when performed in high-volume centers. Profound anatomical knowledge, advanced laparoscopic skills, and mastering intraoperative ultrasound are essential. No major interinstitutional differences were ascertained.

Introduction: Laparoscopic liver resection (LLR) has been widely adopted. Nevertheless, laparoscopic segment 1 resection requires a high level of expertise due to its challenging anatomical area, even in the open approach. Only case series and single center cohort studies were published. Through this multicenter retrospective cohort study, we assessed the safety and feasibility of this laparoscopic procedure, described its outcomes, and determined interinstitutional differences. Methods: Between 2000-2018, 32 patients underwent LLR of segment 1 in 4 high-volume hepatobiliary units for colorectal liver metastasis (CRLM) (n=22, 68.8%), cholangiocarcinoma (n=1, 3.1%), other malignancies (n=4, 12.5%), and symptomatic benign lesions (n=5, 15.6%). Simultaneous colorectal and/or additional liver resection was performed in 20 (62,5%) patients. Perioperative and long-term outcomes were reviewed. Postoperative complications were stratified according to the Clavien-Dindo classification with severe complications defined by grade 3 or more. The median (range) follow-up time for the CRLM group was 14 (3-114) months. Results: The median operative time was 155 (29-440) minutes and estimated blood loss was 100 (10-1000) ml. No blood transfusions were required. Three conversions needed to be executed (9.4%), none procedure-related. Severe complications were observed in 2 cases (6.3%) without need for surgery. No postoperative mortality was noticed. In total 32 tumors were resected with a median size of 22 (0-58) mm. The median hospital length was 4 (1-40) days. Cancer recurrence was observed in 12 patients (54.5%) of the CRLM group with a median recurrence-free survival of 10 months. One recurrence occurred at the resection site. Overall survival 5 years after surgery was 82% in this subgroup. Only small interinstitutional differences were observed without major impact on surgical outcomes. Conclusion: LLR of segment 1 is safe and feasible when performed in high-volume centers. Therefore, profound anatomical knowledge, advanced laparoscopic skills and mastering intraoperative ultrasound is required. No major interinstitutional differences were ascertained.

Sphincter-preserving surgery for rectal cancer is often associated with low anterior resection syndrome (LARS). The aim of our study was to determine the prevalence of LARS in our institution and identify possible risk factors for LARS. Furthermore, we evaluated which of the LARS symptoms was considered most disabling by patients and whether or not there is an adaptation of the LARS score over time.