Background: Sepsis is one of the leading causes of early death after a liver transplant, with a frequency of up to 45% and a high death rate of 50% in more severe forms. Standard diagnostic and therapeutic algorithms are often not applicable to this specific population, where immunosuppression, reperfusion injury, and systemic inflammation overlap and generate a clinical picture that is significantly different from sepsis in immunocompetent patients. Methods: This paper analyzes the available literature and clinical experiences of characteristic immune and hemodynamic profiles of sepsis after liver transplants. Biomarkers (IL-6, IL-10, HLA-DR, lactate, and IgM) are discussed as tools for assessing immune status and guiding timely interventions, including the early application of continuous renal replacement therapy (CRRT) and the selective use of IgM-enriched immunoglobulins. Results: Sepsis after liver transplantation frequently unfolds in two phases, an initial hyper-inflammatory response driven by cytokine release and reperfusion injury and a second phase of secondary immunoparalysis characterized by reduced HLA-DR expression and increased anti-inflammatory signaling. The immunometabolic shift appears to influence the clinical course and may inform therapeutic decision-making. The immunoparalysis phase is accompanied by mitochondrial dysfunction and impaired vascular reactivity. This type of mechanism contributes to hemodynamic instability and a reduced response to standard therapy. Individualized monitoring and early use of hemofiltration and immunomodulatory measures can improve results in carefully selected patients. Conclusions: In this setting, an individualized immunometabolic approach may complement standard sepsis management in liver transplant recipients. The introduction of biomarkers of immune function into routine practice and the recognition of early signs of exhaustion of the immune response can assist in timely therapeutic decision-making and improve survival.

Liver graft shortage remains a major limiting factor in contemporary liver transplantation, particularly in the setting of increasing waiting list pressure and constrained donor availability. While the biological quality of donor organs cannot be modified surgically, several operative strategies have been developed to optimize liver utilization and compensate for insufficient graft volume. These include split liver transplantation (SLT), dual-graft living donor liver transplantation (DGLT), auxiliary procedures, and selected multi-graft or hybrid configurations. This review provides an updated and structured overview of surgical concepts aimed at maximizing effective liver mass for transplantation. We discuss indications, technical considerations, and reported outcomes of split, dual, and combined graft approaches, with particular emphasis on graft-to-recipient weight ratio (GRWR), portal inflow modulation, and prevention of small-for-size syndrome. The role of machine perfusion technologies—including normothermic and hypothermic approaches—as enabling tools for graft assessment and safer utilization of partial grafts is also examined. Finally, we address ethical and logistical challenges associated with complex graft strategies and outline future directions in which advances in perfusion, graft assessment, and staged transplantation concepts may further refine patient selection and procedural safety. Collectively, these strategies represent complementary solutions for extending liver transplantation beyond conventional single-graft paradigms in highly selected settings.

Background: Major liver resections that include the removal of four or more Couinaud segments require precise assessment of the future liver remnant (FLR) to prevent post-hepatectomy liver failure (PHLF). Volumetry, although standard in surgical planning, does not always reflect true functional reserve, especially in steatotic, fibrotic or chemotherapy-damaged liver. Methods: This review proposes an integrative physiological framework of functional liver recovery after a major hepatectomy that connects preoperative functional assessments—indocyanine clearance (ICG-PDR), Liver Maximum Function Capacity test (LiMAx) and 99mTc-mebrofenin SPECT/CT—with perioperative hemodynamic, oxidative and metabolic parameters. A narrative literature review was performed using PubMed and Web of Science, covering publications from January 2000 to January 2025. The search combined keywords and MeSH terms such as major hepatectomy, liver regeneration, hemodynamic optimization, oxidative stress and post-hepatectomy liver failure. We focused on clinically relevant studies, including randomized controlled studies and consensus guidelines, and complemented the search by screening the reference lists of selected articles. When direct clinical evidence was limited, a physiologically grounded interpretation was used to support a pragmatic framework for perioperative management. Results: The framework integrates three complementary physiological domains that together determine functional liver recovery. The first relates to hemodynamic stability, including optimal maintenance of arterial and venous pressures as well as portal-splanchnic gradients, which support adequate perfusion and oxygenation of hepatocytes. The second addresses the balance between oxidative stress and antioxidant defense, where the key indicators are the level of lipid peroxidation and endogenous antioxidant capacity. The third domain evaluates the functional ability of the liver through dynamic tests of synthesis and metabolism, such as factor V, indocyanine clearance (ICG-PDR), and the LiMAx test. With the integration of these three domains, a functional profile of liver recovery can be defined, facilitating monitoring of the physiological response in real time and guiding individualized perioperative support to the individual needs of the patient. Conclusions: Functional recovery follows a dynamic continuum, progressing from early reperfusion stress through hemodynamic stabilization to progressive hepatocellular regeneration. Integration of functional FLR assessment with perioperative physiological monitoring may support more individualized prediction of the regenerative capacity and therapeutic decision-making. This physiology-guided perspective extends assessment beyond remnant volume alone to include functional recovery.

Minimally invasive total gastrectomy (MITG) is an established curative approach for gastric cancer. However, variability in technique—particularly regarding lymphadenectomy and anastomosis creation—limits standardisation and optimisation of surgical outcomes. Establishing expert consensus on key technical steps is essential to guide practice, benchmark surgery, and improve quality. To establish expert consensus on the technical components of MITG for oncological indications. A 100-point scoping survey was created by deconstructing MITG into key technical steps based on literature review and expert input. A Delphi process was conducted with an international panel of high-volume oesophagogastric and general surgeons. Panellists rated items based on importance, difficulty, and agreement via online questionnaires. Consensus was defined a priori as >80% agreement. Internal consistency was assessed using Cronbach’s α. Thirty expert surgeons participated in three Delphi rounds, achieving final consensus on 41 statements defining technical standards for MITG. Consensus was reached from 22, 12, and 7 questions across rounds 1, 2, and 3, respectively. Statements addressed critical aspects of lymphadenectomy, reconstruction, and intraoperative decision-making. Cronbach’s α for lymphadenectomy and anastomosis steps was 0.90 and 0.89 in round 1, and 0.85 and 0.78 in round 2, indicating strong internal consistency. Five questions regarding the importance of specific MITG steps and three binary-response questions on anastomosis creation did not reach consensus after three rounds. This is the first international Delphi consensus on technical steps in MITG. The 41 statements provide a foundation for developing surgical quality assessment tools to standardise technique, enable benchmarking, and improved outcomes from MITG.

Portopulmonary hypertension (PoPH) and hepatopulmonary syndrome (HPS) present two vascular complications of portal hypertension, which make opposite extremes occur against the same pathophysiological background. In PoPH, vasoconstriction predominates, along with gradual remodeling of pulmonary arteries, while HPS develops due to pathological vasodilation and creation of intrapulmonary shunts. Even though they come about by different mechanisms, both disorders significantly affect quality of life, survival, and the possibility of liver transplant. In the early phases, in clinical practice, symptoms are mainly mild and nonspecific, and overlapping with symptoms of advanced liver disease often delays forming a diagnosis. In PoPH, elevated pressures in pulmonary arteries and increased vascular resistance are observed, while HPS exhibits arterial hypoxemia with normal or lowered pulmonary pressure. Standard diagnostic workup includes echocardiography, right-heart catheterization, and analysis of the arterial gases. In patients with severe PoPH, pronounced pulmonary hypertension can represent absolute contraindication for liver transplantation due to risk of acute right heart failure during operation. Conversely, HPS usually resolves itself after a successful transplant, which confirms that the transplant is an indication of being potentially curative. Therapeutic possibilities for both states are still limited. In PoPH, specific vasodilators and supportive measures are applied, while HPS treatment is mostly supportive, directed at maintaining oxygenation until the transplant. Future research should be focused on the development of targeted therapies that address vascular remodeling, angiogenesis, and oxidative stress, as well as on the standardization of diagnostic criteria and multicentric cooperation. This approach would facilitate earlier recognition, a precise assessment of transplantability, and a better long-term outcome for patients with portal hypertension and lung vascular complications. Key Points: Portopulmonary hypertension (PoPH) and hepatopulmonary syndrome (HPS) represent two opposite vascular complications of portal hypertension, posing distinct challenges for liver transplantation. This review summarizes their pathophysiology, diagnostic pathways, and therapeutic strategies, emphasizing the importance of hemodynamic profiling and multidisciplinary management to optimize transplant outcomes.

Typical gallstone ileus includes small intestine obstruction caused by the gallstone passing from the gallbladder through the common bile duct (CBD). The case of gallstone ileus with simultaneous obstructive jaundice and intestinal ischemia is an extremely rare scenario. Computed tomography of the abdomen and pelvis is the method of choice for the diagnosis. While some cases may be treated conservatively, surgery is often required, with the approach tailored to the patient's general condition and medical history. Hereby, we present a case of an 88-year-old lady with gallstone ileus, obstructive jaundice, and radiologic signs of intestinal ischemia. Urgent surgery revealed a 3 cm gallstone in the ischemic distal jejunum and another in the CBD. Cholecystectomy, duodenal wall repair, choledochotomy with stone extraction, and T-drainage were performed. The patient was discharged from the hospital on the 25th postoperative day, and 1 year after the surgery, is in good general condition.

In this article, we comment on the article by Wang et al published in the recent issue of the World Journal of Gastroenterology Surgery . Most prominent advancements in liver surgery in the last two decades are related to refinements in surgical technique (extraglissonean approach) and advancements in surgical technology (laparoscopy and robotics). In this article, authors present both these aspects: Laparoscopic segmentectomy using extraglissonean approach. Furthermore, they describe segmental resections of all 8 segments which is the main novelty that can be observed in the article. By now, extraglissonean approach was thoroughly described mainly in hepatectomies or lateral sectionectomies. Various “hilar gates” are defined which allows safe liver resection by ligating Glissonean pedicles first which is then followed by parenchymal resection. We here focus on past, present and future perspectives of extraglissonean approach and laparoscopic liver resections and comment the value of the presented article.

Liver transplantation represents the only curative method for end-stage liver disorders and certain liver malignancies. Over the last three decades, advancements in immunosuppression, surgical technique, and intensive care measures have resulted in improved patient and graft survival outcomes, but a deficit of donor organs is constantly the major issue that limits our ability to reduce the mortality on the liver transplant waiting list. To address this, marginal grafts and those from donors after cardiac death are increasingly employed, but these strategies necessitated novel methods to improve the preservation and quality of liver grafts and the most promising one is liver machine perfusion (LMP). LMP evolved significantly in the past 10 years, and consequently, it is gradually establishing itself as a standard protocol at many transplant centers. However, many unresolved questions remain concerning the indications, types, and protocols associated with LMP. Therefore, continuous research is necessary to determine optimal guidelines and recommendations for its clinical application. This review aims to analyze the development of liver machine perfusion, including its different modalities underlying mechanisms of operation, and provide an overview of its historical evolution, current status, and future prospects.

BACKGROUND:Hepatic venous outflow obstruction (HVOO) is a rare but serious complication of liver transplantation, particularly in piggyback liver transplantation techniques where the inferior vena cava (IVC) is preserved. CASE SUMMARY:A transplanted liver patient underwent retransplantation due to hepatic artery thrombosis and subsequently developed HVOO caused by graft compression of the IVC. A novel approach using a retrohepatic tissue expander effectively relieved the IVC compression, restored venous outflow, and stabilized hemodynamics. We discuss this case in the context of current treatment options and advances in HVOO management, from endovascular interventions such as balloon dilation and stenting to innovative surgical solutions such as graft repositioning and retrohepatic implants. CONCLUSION:This case shows how important personalized treatments are for managing HVOO and how tissue expanders can be an adjustable and less invasive option.

Background:Primarily unresectable liver tumors may be approached by the Associating Liver Partition and Portal vein Ligation for Staged Hepatectomy (ALPPS) procedure. Post-hepatectomy liver failure (PHLF) poses the most significant risk factor for poor outcomes. The AST-to-platelets ratio index (APRI)/albumin-to-bilirubin index (ALBI) score has been proposed as an easy and routinely available score to monitor liver function. Here, we explored the predictive capability of the APRI/ALBI score to determine PHLF and perioperative morbidity to help determine the optimal timing of the 2nd stage of ALPPS. Methods:Based on the international multicenter ALPPS registry, patients from 2012 to 2020 with an available APRI/ALBI score were included. Postoperative outcomes (clinically relevant PHLF B + C, 90-day mortality, and severe morbidity (≥ Clavien-Dindo 3b) after ALPPS stage II were assessed. The APRI/ALBI score was monitored perioperatively, and the predictive value was evaluated using logistic regression and receiver operating characteristics. Performance of APRI/ALBI score was compared to the ALPPS futility risk score in this cohort study. Results:Overall, 464 patients from 16 participating centers were included. Clinically relevant PHLF (B + C) was observed in 7.5% of patients, of which 63% ultimately died. After stage I, the APRI/ALBI score gradually recovered. The pre-stage II APRI/ALBI score significantly predicted clinically relevant PHLF [area under the curve (AUC) =0.78; P<0.001], 90-day mortality (AUC =0.67; P=0.002), and severe morbidity (AUC =0.65; P<0.001). Three clinically relevant APRI/ALBI score risk groups were defined: clinically relevant PHLF occurred in 3.1% in the low-, 8.7% in the intermediate-, and 28.0% in the high-risk groups. 90-day mortality was 6.8% in the low-, 15.9% in the intermediate-, and 19.4% in the high-risk groups. Integrated assessment of the established futility risk score in combination with the APRI/ALBI score documented further increased predictive potential for clinically relevant PHLF (AUC 0.81; P<0.001). Conclusions:The APRI/ALBI score allows for simple and dynamic liver function recovery monitoring after the first ALPPS stage. Inadequate recovery of the APRI/ALBI score until ALPPS stage II was associated with PHLF B + C, 90-day mortality, and severe morbidity. With the proposed risk model, optimized timing of the second stage of ALPPS may further increase the safety of this procedure.

Background Hemorrhoidal disease is common in the general population. No papers have been published on its diurnal symptomatology. When experiencing discomfort in the perianal area, it is expected that people will perform a web search for the term “hemorrhoids”, since it is the most prominent proctological disease. Methods Data were retrospectively collected through the Google Trends platform for each European country, with their local translation of the term “hemorrhoids”. The data obtained were averaged for the same clock times on six consecutive days and adjusted for time zones. Greece, Finland, Liechtenstein, Monaco, and Gibraltar were excluded for insufficient data. Turkey and Russia were excluded because of being both in Asia and Europe. Switzerland, Belgium, and Kosovo were excluded for multiple official languages. Data were analyzed for each country separately and Europe altogether. Results In total, 38 010 singular data points were collected. The results were summed in 8-minute intervals and normalized to a scale 0-100 for visual clarity. Data was population-weighted to account for different population sizes. In every European country, the peak interest in the word “hemorrhoids” is at night, between two and six in the morning. The average time of googling the term is 03:44 am. A clear pattern of daily oscillations for each country and Europe was observed. Conclusion Hemorrhoidal disease appears to be symptomatic at night. Google Trends platform is a novel, indirect method of collecting data on symptomatology, outcomes, and seasonal incidence of diseases. It is a free tool, provides large-scale data, and bypasses financial and time constraints.

Background/Objectives: Our study describes hyperbaric oxygen therapy (HBOT) as an additional therapy in the conservative treatment of Crohn’s disease (CD) and its benefit in the early postoperative period to prevent surgical complications and improve gastrointestinal motility. Methods: This retrospective study evaluated HBOT in patients hospitalized at the Clinical Hospital Center Split for complications of CD between 2015 and 2020. Patients (N = 61) aged 19 to 67 with perianal fistulas, abscesses, fistulas, obstruction, stenosis, or bleeding were included, excluding those with ulcerative colitis or requiring intensive care. Patients were retrospectively divided into conservatively and surgically treated groups, and HBOT was administered over 15–25 days, with treatment lasting 60 min at 2.2 absolute atmospheres (ATA). We analyzed treatment outcomes between the HBOT-treated surgical and conservative groups and compared patients treated with HBOT to a cohort from the preceding five years who did not receive HBOT. Results: We treated 61 CD patients with HBOT, including 34 conservatively and 27 surgically treated patients. HBOT significantly reduced disease activity indices (311.7 ± 59.1 vs. 114 ± 29.8; 203.6 ± 24.1 vs. 83.8 ± 15, for conservatively treated patients, and 352.8 ± 45.7 vs. 109 ± 22.8; 270.4 ± 19.7 vs. 140.3 ± 10.6 for surgically treated patients) and accelerated bowel peristalsis recovery, with 94.1% of conservatively treated patients achieving remission. Comparison with a historical cohort showed faster recovery and improved outcomes in the HBOT group. Conclusions: HBOT is useful in postponing or avoiding surgical treatment, and in operated patients, it improves postoperative recovery and reduces the rate of postoperative complications.

Endoscopic retrograde cholangiopancreatography (ERCP) is an important technique for treating biliary obstruction. A case report of a 75-year-old male with diagnosed choledocholithiasis and cholangitis was presented. He had a history of hepatic surgery 45 years ago, and during the ERCP, an unusual clinical scenario was encountered. Retained extraction basket during ERCP is a rare but known complication and there are no standard recommendations to manage it. To our knowledge, this is the first case report described in the literature with retention of an extraction basket in surgical sutures at ERCP and the longest period from surgery to stone formation in the biliary system. This case report aims to emphasize that in patients with a history of hepatobiliary surgery, postoperative material can cause complications during ERCP.

Abstract Background Perioperative morbidity and mortality remain a point of concern for the Associating Liver Partition and Portal Vein Ligation for Staged hepatectomy (ALPPS) procedure. Post-hepatectomy liver failure (PHLF) after the second step poses the most significant risk factor for futile outcome. Recovery of liver function after the first step of ALPPS is critically important to allow for sufficient liver function after this surgery. The APRI+ALBI score has been proposed as an easily assessable score to monitor liver function and its dynamic recovery. Aims We explored if the APRI+ALBI score was able to assess liver function recovery after the first step of ALPPS and allow for optimal timing of the 2nd step. Methods Based on the ALPPS registry, patients from 2012 to 2020 with available APRI+ALBI score were included. Postoperative outcomes (PHLF A – C, PHLF B + C, 90-day mortality and severe morbidity) were defined as per standard definitions. The APRI/ALBI score was monitored perioperatively. Results Overall, 464 patients from 16 international participating centers in the ALPPS registry were included. Clinically relevant PHLF (B + C) was observed in 7.5 % and of these 63 % of patients ultimately died due to liver failure. The APRI+ALBI score immediately increased after each surgical intervention and continuously decrease thereafter. Failure of the APRI+ALBI score to decrease until the 2nd step of ALPPS predicted PHLF B+C (p = 0.001; AUC 0.78). Particularly patients with high APRI+ALBI scores and short interstage intervals were at risk to develop PHLF B+C. Conclusion The APRI+ALBI score objectifies liver function recovery after the 1st step of ALPPS and failure to sufficiently decreased is associated with a higher risk for PHLF B+C. This might allow for optimized planning of the 2nd step of ALPPS to allow for sufficient liver function recovery to minimize the risk for PHLF B+C and associated futile outcome.

BACKGROUND Pancreatic resection is still associated with high morbidity rates and delayed postpancreatectomy hemorrhage (PPH) is the most feared complication as it may lead to hemorrhagic shock or serious septic complications. Today, endovascular approach represent safe and efficient method for minimally invasive management of extraluminal PPH. CASE SUMMARY We describe four patients whose postoperative recovery after pancreatic resection was complicated by postoperative pancreatic fistula (POPF) and visceral artery hemorrhage. In all cases endovascular approach was utilized and it resulted in satisfactory outcomes. We discuss modern diagnostic and therapeutic approach in this clinical scenario. CONCLUSION PPH is relatively uncommon, but it is a leading cause of surgical mortality after pancreatic surgery. Careful monitoring and meticulous follow-up are required for all patients post-operatively, especially in the case of confirmed POPF, which is the most significant risk factor for the development of a PPH. Angiography as a diagnostic and therapeutic method may be an optimal first-line treatment for the management of delayed PPHs. In our experience, endovascular treatment for hemorrhagic complications of pancreatic resections has shown satisfactory results.

Background/Objectives: Acute necrotizing pancreatitis (ANP) with secondary infection of necrotic tissue is associated with a high rate of complications and mortality. The optimal approach is still debatable, but the minimally invasive modality has gained great attention in the last decade as it follows the principle of applying minimal surgical trauma to achieve a satisfying therapeutic objective. We compared clinical outcomes between the step-up approach (SUA) and open necrosectomy (ON) in the treatment of acute necrotizing pancreatitis. Methods: A prospective cohort study over the period of 2011–2021 in a university teaching hospital was performed. Results of 99 consecutive patients with ANP who required surgical/radiological intervention were collected. A case match analysis (2:1) was performed, and the final groups comprised 40 patients in the OA group and 20 patients in the SUA group. Demographic, clinicopathologic, and treatment data were reviewed. Results: Baseline characteristics and disease severity were comparable between the two groups. The patients from the SUA group had a significantly lower morbidity rate and rate of pancreatic insufficiency. Death occurred in 4 of 20 patients (20%) in the SUA group and in 11 of 40 patients (27.5%) in the ON group (risk ratio with the step-up approach, 0.72; 95% confidence interval, 0.26 to 1.99; p = 0.53). Conclusions: A minimally invasive step-up approach provides comparable outcomes to open necrosectomy in the treatment of ANP with infected pancreatic necrosis. While mortality and hospital stay were comparable between the groups, morbidity and pancreatic insufficiency were significantly lower in the SUA group. Further studies on a larger number of patients are required to define the place of SUA in the modern treatment of ANP.

A 77-year-old male patient was treated surgically because of mesenterial ischemia. Gangrenous sigmoid and left colon were resected and unipolar colostomy was created at the level of the middle transverse colon. Standard abdominal drain (size 18) was placed in the left paracolic gutter. At second surgery a loop of small bowel was adjacent to distal part of the drain and there were two ischemic patches caused by vacuum effect of the drain holes. This report highlights the possible dangers of abdominal drain placement and discuss ways to prevent it.

Background and aimsColorectal liver metastases (CRLMs) represent the most prevalent form of secondary liver tumors, and insufficient future liver remnant (FLR) often leads to unresectability. To tackle this challenge, various methods for stimulating liver hypertrophy have been developed including portal vein embolization (PVE), associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and the newest one, liver venous deprivation (LVD). ALPPS was thoroughly studied over the last decade and it has been shown to induce rapid and intensive FLR hypertrophy. The objective of this study was to assess whether the localization of the liver transection line during the initial stage of ALPPS correlates with the degree of FLR hypertrophy.MethodsA retrospective, multicentric study was conducted, and we analyzed all consecutive patients with CRLMs who underwent ALPPS over the eight-year period. Patients were categorized into two groups based on the type of resection—right trisectionectomy (ERH) or right hemihepatectomy (RH) respectively. The degree of hypertrophy (DH), its correlation with FLR and postoperative outcomes were assessed.ResultsThe cohort consisted of 136 patients (72 in the ERH group and 64 in the RH group). Baseline characteristics, hypertrophy interval, and total liver volume showed no significant differences between the groups. DH was greater in the ERH group (83.2% vs. 62.5%, p = 0.025). A strong negative correlation was observed between FLR volume and DH in both groups. Postoperative outcomes and one-year survival were comparable between the groups.ConclusionsFLR hypertrophy is influenced by the localization of the liver transection line in ALPPS. Furthermore, correlation analysis indicated that a smaller estimated FLR is associated with greater DH. No statistical difference in outcomes was noted between the groups.

Colorectal cancer (CRC) is the third most common and the second deadliest cancer in the world with higher frequency in developed countries.In Croatia, CRC is the second most common cancer in women, and the third most common in men.With about 3,400 newly diagnosed cases and 2,100 deaths, CRC is after lung cancer, the second deadliest malignant disease in Croatia.Secondary prevention of CRC consists of measures aimed to reduce serious consequences of this disease.Screening is part of secondary prevention used for early and timely detection of the disease.It is used for detection of disease at an earlier stage, and sometimes before the onset of the disease.Detecting cancer at an early stage can reduce the severity and mortality of the disease.Screening tests must meet certain criteria such as simplicity and safety, sufficient sensitivity and specificity, cost-effectiveness, and the possibility of further action in the event of a positive test.The screened disease must be precisely defined, the incidence must be known, and the onset of the disease must be slow.It is necessary to allow equity of procedures and to clearly define cut-off values for healthy and sick individuals.Various tests are nowadays used for CRC screening.There are stool tests, endoscopic procedures, radiological imaging, and blood marker tests.Each test has its own number of advantages and disadvantages.For screening, it is important to choose not only the test with the highest sensitivity and specificity, but also the one for which the largest part of the population will be willing to adhere to with acceptable technical characteristics.