INTRODUCTION:Malignant bowel obstruction is common in colorectal cancer and may require high-risk emergency surgery. A structured four-stage obstruction protocol may improve outcomes through early decompression and optimisation, thereby preventing deterioration, reducing acute resections and stoma formation, and minimising morbidity and mortality. This study evaluated clinical outcomes of this protocol. METHODS:The protocol categorises patients by symptom severity and colonic distension, with stage-specific management and routine reassessment for improvement or deterioration. Deterioration was defined as worsening of symptoms requiring escalation to a higher stage and more intensive care. This retrospective study included patients treated between 2018 and 2024. RESULTS:Of 319 patients, 236 received curative and 83 palliative treatment. Stage distribution (curative/palliative): stage 1 (184/59), stage 2 (19/11), stage 3 (20/6), stage 4 (13/7). (Semi-)acute resections occurred more frequently in higher stages: 1% (stage 1), 6% (stage 2), 25% (stage 3), 15% (stage 4) (p < 0.001). Overall, 6% of curative patients deteriorated: 3% (stage 1), 5% (stage 2), 30% (stage 3), and 8% (stage 4). In curative stage 3, acute resection was avoided in 75% treated with stenting or nasogastric decompression. In the palliative group, all stage 3-4 patients received a stent or stoma without deterioration. CONCLUSION:The four-stage obstruction protocol effectively manages colorectal cancer-related obstruction. In 94% of curative patients, deterioration was prevented, avoiding emergency surgery and its risks. While emergency resection was previously considered standard in stage 3, the protocol avoided this in most patients. Accurate staging and close monitoring remain essential to prevent deterioration.

BACKGROUND:Completion total mesorectal excision (cTME) after local excision of early rectal cancer is associated with substantial morbidity and impaired functional outcomes. This study aimed to assess the oncological outcomes of adjuvant chemoradiotherapy as an organ-preserving alternative in patients with high-risk pT1 and low-risk pT2 rectal cancer. METHODS:This multicentre, open-label, randomised, controlled, phase 3, non-inferiority trial was conducted at 25 hospitals across the Netherlands and France. Patients aged 18 years or older with locally excised high-risk pT1 and low-risk pT2 rectal cancer located below the sigmoid takeoff were randomly assigned (1:1), via an interactive web-response system, to adjuvant chemoradiotherapy (25 × 1·8 Gy limited to the mesorectum, with oral capecitabine 825 mg/m2 twice daily) or cTME through an interactive web-response system. Randomisation was done via minimisation with stratification for age (<75 years vs ≥75 years), American Society of Anaesthesiologists (ASA) classification (ASA 1 vs ASA ≥2), type of local excision (surgical vs endoscopic), pathological tumour stage (high-risk pT1 vs low-risk pT2), and resection margin status (<1 mm vs ≥1 mm). The primary endpoint was 3-year locoregional recurrence, with a prespecified non-inferiority margin of 7%. Secondary endpoints included unsalvageable locoregional recurrence, disease-free survival, overall survival, treatment-related morbidity within 30 days (assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events criteria for adjuvant chemoradiotherapy and the Clavien-Dindo classification and the Comprehensive Complication Index for cTME), stoma rate, and quality of life. All comparative analyses were conducted according to the intention-to-treat (ITT) and per-protocol principles. The trial is registered on ClinicalTrials.gov, NCT02371304. On Oct 1, 2024, the trial was converted to a patient-preference design due to loss of equipoise before reaching its target sample size of 302 patients. The current analysis includes patients randomly assigned until this transition. Enrolment is ongoing within the patient-preference design. FINDINGS:Between Nov 1, 2015, and Sept 14, 2024, 202 patients were randomly assigned, of whom 197 were included in the ITT analysis (adjuvant chemoradiotherapy, n=101; cTME, n=96). Of these patients, 118 (59·9%) were male and 79 (40·1%) female; mean age was 64·7 years (SD 7·4), and mean BMI was 26·5 kg/m2 (SD 4·0). After a median follow-up of 50·0 months (IQR 27·0-62·0), five locoregional recurrences were reported: four in the adjuvant chemoradiotherapy group and one in the cTME group. Estimated 3-year locoregional recurrence rates were 5·0% (95% CI 1·6-11·3) after adjuvant chemoradiotherapy and 1·1% (0·0-5·5) after cTME. Adjuvant chemoradiotherapy did not meet the non-inferiority margin of 7% for 3-year locoregional recurrence (difference 3·9% [90% CI 0·0-9·4]; one-sided pnon-inferiority=0·16). However, four of the five locoregional recurrences (three in the adjuvant chemoradiotherapy group and one in the cTME group) were successfully salvaged, resulting in a 3-year unsalvageable locoregional recurrence rate of 1·3% (95% CI 0·1-6·1) after adjuvant chemoradiotherapy and 0·0% (0·0-5·6) after cTME. 3-year disease-free survival was 92·0% (95% CI 84·4-96·4) after adjuvant chemoradiotherapy compared with 96·3% (89·7-99·1) after cTME (hazard ratio [HR] 3·20 [95% CI 0·88-11·6]). 3-year overall survival was similar in both groups (98·9% [95% CI 94·1-99·9] for adjuvant chemoradiotherapy and 98·9% [93·7-99·9] for cTME; HR 1·64 [95% CI 0·22-18·0]). Treatment-related toxicity occurred in 82 (78%) of 105 patients after adjuvant chemoradiotherapy (grade ≥3 in ten [9·5%] of 105 patients). Post-operative complications occurred in 32 (43·8%) of 73 patients after cTME (Clavien-Dindo grade ≥IIIa in 11 [15·1%] patients; median Comprehensive Complication Index 21·8 [IQR 8·7-39·7]). 3-year stoma rates were significantly lower after adjuvant chemoradiotherapy (2·6% [95% CI 0·5-8·3]) versus cTME (45·4% [35·0-55·3]; p<0·0001). 1-year quality-of-life outcomes were comparable or favoured adjuvant chemoradiotherapy across nearly all domains. INTERPRETATION:Non-inferiority of adjuvant chemoradiotherapy compared with cTME for 3-year locoregional recurrence could not formally be demonstrated. However, loss of equipoise hampered patient accrual, precluding the trial from reaching its prespecified sample size. Although the 3-year locoregional recurrence rate numerically favoured cTME, adjuvant chemoradiotherapy resulted in low rates of unsalvageable locoregional recurrence, and substantially reduced treatment-related morbidity and stoma rates. These findings challenge cTME as the standard of care for patients with locally excised high-risk pT1 and low-risk pT2 rectal cancer. FUNDING:Dutch Cancer Society.

Background Patients with colorectal liver-only metastases (CRLM) eligible for local treatment (resection/ablation) do not always receive this potentially curative treatment due to the lack of clear resectability criteria and expertise in centres not performing liver surgery. We evaluated the potential value of a liver expert panel in daily practice. Methods All patients with CRLM starting with systemic treatment in centres not performing liver surgery between 2016 and 2020 were identified in the Netherlands Cancer Registry. A panel of liver surgeons retrospectively re-evaluated patients’ imaging for resectability before and two-monthly during systemic treatment. Results Sixty-three patients were included from 24 hospitals requiring a total of 544 resectability assessments by individual panel surgeons. The panel considered 18 (29 %) patients to have resectable CRLM before starting systemic treatment, which increased to 43 (68 %) after up to three evaluations. Eighteen (29 %) patients considered resectable by the panel at any time received no local treatment of whom 9 (50 %) were not referred to a liver surgeon. Conclusion In non-liver-surgery centres, over a quarter of patients technically eligible for local treatment of initially unresectable CRLM, sometimes mistakenly categorised as such, did not receive this. This stresses the need for liver expert panels in daily practice to increase local treatment rates.

BACKGROUND:Considerable variability exists among liver surgeons in assessing resectability and local treatment planning of initially unresectable colorectal cancer liver-only metastases (CRLM). This study analysed short-term and survival outcomes of one-stage versus two-stage surgery for CRLM. METHODS:Patients with initially unresectable CRLM were included from the phase 3 CAIRO5 study. In patients in whom both one-stage and two-stage approaches were suggested by individual panel surgeons, these approaches were compared. The study population includes only patients for whom both approaches were discussed by the panel surgeons. Overall survival curves were estimated with the Kaplan-Meier method and compared with the two-sided stratified log-rank test. Other surgical and postoperative outcomes were compared using a two-sample t test and Pearson's χ2 test or Fisher's exact test, as appropriate. RESULTS:Local surgeons planned one-stage versus two-stage surgery in 53 versus 51 patients, respectively. In the one-stage versus two-stage surgery groups, the median age was 59 (interquartile range (i.q.r.) 52-69) versus 59 (i.q.r. 53-68) years, respectively, and the median number of CRLM was 9 (i.q.r. 6.5-13) versus 10 (i.q.r. 7.5-14), respectively. Median overall survival was 46.5 versus 34.0 months (HR 0.61; 95% confidence interval 0.38 to 0.99; P = 0.043) with planned one-stage versus two-stage surgery, respectively. In one-stage versus two-stage surgery, Clavien-Dindo grade ≥ 3 complications occurred in 11 versus 13 patients (P = 0.567), portal vein embolization was performed in 2 versus 41 patients (P < 0.001), and local treatment was complete (R0/R1 resection or ablation of all CRLM) in 52 versus 29 patients (P < 0.001), respectively. Major liver resection was performed in 19 versus 28 patients with complete planned one-stage versus two-stage surgery, respectively, with a corresponding 32 versus 12 patients undergoing ablation. CONCLUSION:One-stage surgery with/without ablation appears to be the optimal treatment approach for patients with initially unresectable CRLM for whom both one- and two-stage approaches are considered. Nonetheless, two-stage surgery remains vital for complex CRLM.

INTRODUCTION:This study aimed to assess whether total tumor volume (TTV) outperforms RECIST1.1 for treatment response assessment in patients with colorectal liver metastases (CRLM), and to investigate TTV as a predictive biomarker for the optimal systemic treatment regimen for individual patients with initially unresectable CRLM. METHODS:Patients with initially unresectable liver-only CRLM from the phase 3 CAIRO5 trial (NCT02162563) were included. All patients received induction systemic treatment. Baseline TTV and changes in TTV and RECIST1.1 in response to systemic treatment were calculated using the CT scans before systemic treatment and at first follow-up, and were assessed for their prognostic and predictive value with multivariable Cox regression models. Results In total, 425 patients were included. In multivariable analyses, baseline TTV (adjusted HR [aHR] for 100 mL vs 10 mL, 2.44 [95 % CI, 1.25-4.76]; P = 0.006) and relative change in TTV were the strongest predictors for OS (aHR for 0 % change vs 50 % decrease, 2.57 [1.83-3.60]; P < 0.0001). In contrast, RECIST1.1 was not independently associated with OS (aHR for partial response vs progressive disease, 0.63 [95 % CI, 0.33-1.20]). Higher baseline TTV predicted a stronger treatment benefit of FOLFOX-/FOLFIRI-bevacizumab vs FOLFOX-/FOLFIRI-panitumumab on OS (Pinteraction=0.017). CONCLUSION:This study demonstrates that TTV (i) outperforms traditional risk factors for OS prognostication, and (ii) may be a more accurate and sensitive treatment response assessment method compared to the currently used RECIST1.1 system in patients with initially unresectable CRLM. Moreover, TTV assessment is a promising approach for individualized clinical decision-making between bevacizumab and panitumumab.

Background Delayed gastric emptying is a major contributor to prolonged hospital stay following pancreatoduodenectomy. Although enhanced recovery after surgery guidelines recommend unrestricted feeding after pancreatoduodenectomy, nationwide studies evaluating the impact of different feeding strategies after surgery on delayed gastric emptying and length of hospital stay are limited. This study aimed to identify the use and impact of different feeding strategies after pancreatoduodenectomy on delayed gastric emptying and length of hospital stay. Methods This nationwide cohort study included consecutive patients after pancreatoduodenectomy from the Dutch Pancreatic Cancer Audit (2021-2023). Primary endpoints were delayed gastric emptying grade B/C and length of hospital stay. Feeding strategies were categorized based on structured interviews with representatives from 15 centres. Multilevel analysis was used to assess associations between feeding strategy, delayed gastric emptying, and length of hospital stay. Predictors of delayed gastric emptying were determined. Results Overall, 2354 patients undergoing pancreatoduodenectomy were included, of whom 526 (23%) developed delayed gastric emptying grade B/C. Median length of hospital stay was 13 days longer in patients with delayed gastric emptying (23 versus 10 days; P < 0.001). Feeding strategies were: unrestricted feeding (3 centres, 637 patients; delayed gastric emptying 18%); step-up feeding (9 centres, 1462 patients; delayed gastric emptying 24%); and artificial feeding (3 centres, 255 patients; delayed gastric emptying 25%). No association was observed between feeding strategy and delayed gastric emptying: step-up versus unrestricted feeding (odds ratio 1.14, 95% confidence interval 0.53 to 2.47) and artificial versus unrestricted feeding (odds ratio 1.76, 0.65 to 4.73). Similarly, no association was found between feeding strategy and length of hospital stay. The strongest predictor of delayed gastric emptying was pancreatic fistula after surgery (odds ratio 3.16, 2.47 to 4.05). Conclusion This study found no significant association between feeding strategy and incidence of delayed gastric emptying or length of hospital stay after pancreatoduodenectomy. Efforts to reduce delayed gastric emptying should focus on reducing pancreatic fistula after surgery.

Background: Unfavorable intraoperative findings or incidents during minimally invasive liver surgery may necessitate conversion to open surgery. This study aimed to identify predictors for conversion in minimally invasive liver surgery and gain insight into outcomes following conversions. Methods: This nationwide, retrospective cohort study compared converted and non-converted minimally invasive liver surgery procedures using data from 20 centers in the Dutch Hepatobiliary Audit (2014-2022). Propensity score matching was applied. Subgroup analyses of converted robotic liver resection versus laparoscopic liver resection and emergency versus non-emergency conversions were performed. Predictors for conversions were identified using backward stepwise multivariable logistic regression. Results: Of 3,530 patients undergoing minimally invasive liver surgery (792 robotic liver resection, 2,738 laparoscopic liver resection), 408 (11.6%) were converted (4.9% robotic liver resection, 13.5% laparoscopic liver resection). Conversion was associated with increased blood loss (580 mL [interquartile range 250-1,200] vs 200 mL [interquartile range 50-500], P < .001), major blood loss (>= 500 mL, 58.8% vs 26.7%, P < .001), intensive care admission (19.0% vs 8.4%, P = .005), overall morbidity (38.9% vs 21.0%, P < .001), severe morbidity (17.9% vs 9.6%, P = .002), and a longer hospital stay (6 days [interquartile range 5-8] vs 4 days [interquartile range 2-5], P < .001) but not mortality (2.2% vs 1.2%, P = .387). Emergency conversions had increased intraoperative blood loss (1,500 mL [interquartile range 700-2,800] vs 525 mL [interquartile range 208-1,000], P < .001), major blood loss (87.5% vs 59.3%, P = .005), and intensive care admission (27.9% vs 10.6%, P = .029), compared with non-emergency conversions. Robotic liver resection was linked to lower conversion risk, whereas American Society of Anesthesiologists grade >= 3, larger lesion size, concurrent ablation, technically major, and anatomically major resections were risk factors. Conclusion: Both emergency and non-emergency conversions negatively impact perioperative outcomes in minimally invasive liver surgery. Robotic liver resection reduces conversion risk compared to laparoscopic liver resection. (c) 2024 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

In an era of increasing demands on healthcare services, the development of regional oncology networks including care pathways may be instrumental to improve the efficiency and quality of care. However, developing such networks involving numerous stakeholders and hospitals is challenging as no templates exist. This study evaluates the development of a large regional network with the objective to provide a practical template. A multicentre survey was conducted between October 1, 2024 and January 31, 2025. Clinicians from the departments of medical oncology, surgery, gastroenterology, pathology, radiology, nuclear medicine, and radiotherapy at the 13 hospitals in the OncoNoVo+ regional oncology network were invited. The survey included open-ended, multiple-choice, and slider questions (score range 0–100 on a visual analogue scale), focusing on baseline characteristics (n = 7), functioning of the network and care pathways (n = 16), and the development process of the care pathways (n = 6). Overall, 216 medical specialists, researchers, nurse specialists, and case-managers from 13 hospitals developed six care pathways (esophagogastric, pancreatic, small intestinal, rectal, liver, and biliary tract cancer). In the survey, 135 (63

Importance:In patients with colorectal cancer and unresectable liver-only metastases (CRLM), treatment with folinic acid, fluorouracil, and oxaliplatin (FOLFOX) plus irinotecan (FOLFOXIRI) and bevacizumab vs FOLFOX/folinic acid, fluorouracil, and irinotecan (FOLFIRI) plus bevacizumab increased progression-free survival, response, and R0/R1 resection/ablation rates, as well as toxic effects in RAS/BRAFV600E-variant and/or right-sided tumors. FOLFOX/FOLFIRI-panitumumab vs FOLFOX/FOLFIRI-bevacizumab increased response at the cost of more toxic effects in RAS/BRAFV600E wild-type, left-sided tumors. Objective:To present long-term outcomes of treatment with FOLFOXIRI plus bevacizumab vs FOLFOX/FOLFIRI plus bevacizumab and FOLFOX/FOLFIRI plus panitumumab vs FOLFOX/FOLFIRI + bevacizumab. Design, Setting, and Participants:The randomized phase 3 CAIRO5 trial included patients with initially unresectable CRLM in 46 Dutch centers and 1 Belgian center between November 2014 and January 2022. A liver expert panel repeatedly evaluated resectability. Intervention:Patients with RAS/BRAFV600E-variant and/or right-sided tumors randomly received FOLFOX/FOLFIRI-bevacizumab (group 1) or FOLFOXIRI-bevacizumab (group 2), and those with RAS/BRAFV600E wild-type, left-sided tumors received FOLFOX/FOLFIRI-bevacizumab (group 3) or FOLFOX/FOLFIRI-panitumumab (group 4). Adjuvant chemotherapy (ACT) after complete local treatment was recommended but not standard. Main Outcomes and Measures:Overall survival (OS) was analyzed as a secondary outcome. Other outcomes were post hoc analyses. Results:A total of 530 patients (327 male [62%] and 203 female individuals [38%]; median age, 62 [IQR, 54-69] years) were randomized: 148 in group 1, 146 in group 2, 118 in group 3, and 118 in group 4. The median OS in group 1 was 23.6 (95% CI, 20.1-27.5) vs 24.1 (95% CI, 21.0-30.9) months in group 2 (hazard ratio [HR], 0.90; 95% CI, 0.70-1.17; P = .44), and 39.9 (95% CI, 30.7-44.6) in group 3 vs 38.3 (95% CI, 35.3-51.3) months in group 4 (HR, 0.95; 95% CI, 0.68-1.32; P = .75). OS was longest after complete local treatment without early (≤6 months) recurrence (64.3 months; 95% CI, 57.6 to not reached) and salvage local treatment options after early recurrence (58.9; 95% CI, 47.3 to not reached), followed by patients without salvage local treatment after early recurrence (30.5; 95% CI, 24.4-33.4) and with incomplete local treatment (28.7; 95% CI, 25.9-38.3), and worst in patients with continued unresectability (18.3; 95% CI, 15.7-20.0). After confounder adjustment, ACT was associated with longer OS (HR, 0.66; 95% CI, 0.44-0.98) and relapse-free survival (HR, 0.65; 95% CI, 0.48-0.88) and less early recurrence without salvage local treatment (odds ratio, 0.46; 95% CI, 0.25-0.85). Conclusions and Relevance:These results support using FOLFOX/FOLFIRI-bevacizumab for patients with initially unresectable CRLM irrespective of RAS/BRAFV600E status and tumor sidedness. Patients with complete local liver treatment with salvage local treatment in case of early recurrence had the longest OS. ACT might be considered for these patients. Trial Registration:ClinicalTrials.gov NCT02162563.

IMPORTANCE Unintended tumor-positive resection margins occur frequently during minimally invasive surgery for colorectal liver metastases and potentially negatively influence oncologic outcomes. OBJECTIVE To assess whether indocyanine green (ICG)-fluorescence-guided surgery is associated with achieving a higher radical resection rate in minimally invasive colorectal liver metastasis surgery and to assess the accuracy of ICG fluorescence for predicting the resection margin status. DESIGN, SETTING, AND PARTICIPANTS The MIMIC (Minimally Invasive, Indocyanine-Guided Metastasectomy in Patients With Colorectal Liver Metastases) trial was designed as a prospective single-arm multicenter cohort study in 8 Dutch liver surgery centers. Patients were scheduled to undergo minimally invasive (laparoscopic or robot-assisted) resections of colorectal liver metastases between September 1, 2018, and June 30, 2021. EXPOSURES All patients received a single intravenous bolus of 10 mg of ICG 24 hours prior to surgery. During surgery, ICG-fluorescence imaging was used as an adjunct to ultrasonography and regular laparoscopy to guide and assess the resection margin in real time. The ICG-fluorescence imaging was performed during and after liver parenchymal transection to enable real-time assessment of the tumor margin. Absence of ICG fluorescence was favorable both during transection and in the tumor bed directly after resection. MAIN OUTCOMES AND MEASURES The primary outcome measure was the radical (R0) resection rate, defined by the percentage of colorectal liver metastases resected with at least a 1 mm distance between the tumor and resection plane. Secondary outcomes were the accuracy of ICG fluorescence in detecting margin-positive (R1; <1 mm margin) resections and the change in surgical management. RESULTS In total, 225 patients were enrolled, of whom 201 (116 [57.7%] male; median age, 65 [IQR, 57-72] years) with 316 histologically proven colorectal liver metastases were included in the final analysis. The overall R0 resection rate was 92.4%. Re-resection of ICG-fluorescent tissue in the resection cavity was associated with a 5.0% increase in the R0 percentage (from 87.4% to 92.4%; P < .001). The sensitivity and specificity for real-time resection margin assessment were 60% and 90%, respectively (area under the receiver operating characteristic curve, 0.751; 95% CI, 0.668-0.833), with a positive predictive value of 54% and a negative predictive value of 92%. After training and proctoring of the first procedures, participating centers that were new to the technique had a comparable false-positive rate for predicting R1 resections during the first 10 procedures (odds ratio, 1.36; 95% CI, 0.44-4.24). The ICG-fluorescence imaging was associated with changes in intraoperative surgical management in 56 (27.9%) of the patients. CONCLUSIONS AND RELEVANCE In this multicenter prospective cohort study, ICG-fluorescence imaging was associated with an increased rate of tumor margin-negative resection and changes in surgical management in more than one-quarter of the patients. The absence of ICG fluorescence during liver parenchymal transection predicted an R0 resection with 92% accuracy. These results suggest that use of ICG fluorescence may provide real-time feedback of the tumor margin and a higher rate of complete oncologic resection.

Objective: To compare nationwide outcomes of robotic liver resection (RLR) with laparoscopic liver resection (LLR). Background: Minimally invasive liver resection is increasingly performed using the robotic approach as this could help overcome inherent technical limitations of laparoscopy. It is unknown if this translates to improved patient outcomes. Methods: Data from the mandatory Dutch Hepatobiliary Audit were used to compare perioperative outcomes of RLR and LLR in 20 centers in the Netherlands (2014–2022). Propensity score matching (PSM) was used to mitigate selection bias. Sensitivity analyses assessed the impact of the learning curve (≥50 procedures for LLR and ≥25 procedures for RLR), concurrent noncholecystectomy operations, high-volume centers, and conversion on outcomes. Results: Overall, 792 RLR and 2738 LLR were included. After PSM (781 RLR vs 781 LLR), RLR was associated with less blood loss (median: 100 mL [interquartile range (IQR): 50–300] vs 200 mL [IQR: 50–500], P = 0.002), less major blood loss (≥500 mL,18.6% vs 25.2%, P = 0.011), less conversions (4.9% vs 12.8%, P < 0.001), and shorter hospital stay (median: 3 days [IQR: 2–5] vs 4 days [IQR: 2–6], P < 0.001), compared with LLR. There were no significant differences in overall and severe morbidity, readmissions, mortality, and R0 resection rate. Sensitivity analyses yielded similar results. When excluding conversions, RLR was only associated with a reduction in reoperations (1.1% vs 2.7%, P = 0.038). Conclusion: In this nationwide analysis, RLR was associated with a reduction in conversion, blood loss and length of hospital stay without compromising patient safety, also when excluding a learning curve effect. The benefits of RLR seem to be mostly related to a reduction in conversions.

BACKGROUND:Approximately 70% of patients with colorectal liver metastases (CRLM) experiences intrahepatic recurrence after initial liver resection. This study assessed outcomes and hospital variation in repeat liver resections (R-LR). METHODS:This population-based study included all patients who underwent liver resection for CRLM between 2014 and 2022 in the Netherlands. Overall survival (OS) was collected for patients operated on between 2014 and 2018 by linkage to the insurance database. RESULTS:Data of 7479 liver resections (1391 (18.6%) repeat and 6088 (81.4%) primary) were analysed. Major morbidity and mortality were not different. Factors associated with major morbidity included ASA 3+, major liver resection, extrahepatic disease, and open surgery. Five-year OS after repeat versus primary liver resection was 42.3% versus 44.8%, P = 0.37. Factors associated with worse OS included largest CRLM >5 cm (aHR 1.58, 95% CI: 1.07-2.34, P = 0.023), >3 CRLM (aHR 1.33, 95% CI: 1.00-1.75, P = 0.046), extrahepatic disease (aHR 1.60, 95% CI: 1.25-2.04, P = 0.001), positive tumour margins (aHR 1.42, 95% CI: 1.09-1.85, P = 0.009). Significant hospital variation in performance of R-LR was observed, median 18.9% (8.2% to 33.3%). CONCLUSION:Significant hospital variation was observed in performance of R-LR in the Netherlands reflecting different treatment decisions upon recurrence. On a population-based level R-LR leads to satisfactory survival.

BACKGROUND: For open minor hepatectomy, morbidity and recovery are dominated by the incision. The robotic approach may transform this "incision dominant procedure" into a safe outpatient procedure. STUDY DESIGN: We audited outpatient (less than 2 midnights) robotic hepatectomy at 6 hepatobiliary centers in 2 nations to test the hypothesis that the robotic approach can be a safe and effective short-stay procedure. Establishing early recovery after surgery programs were active at all sites, and home digital monitoring was available at 1 of the institutions. RESULTS:A total of 307 outpatient (26 same-day and 281 next-day discharge) robotic hepatectomies were identified (2013 to 2023). Most were minor hepatectomies (194 single segments, 90 bi-segmentectomies, 14 three segments, and 8 four segments). Thirty-nine (13%) were for benign histology, whereas 268 were for cancer (33 hepatocellular carcinoma, 27 biliary, and 208 metastatic disease). Patient characteristics were a median age of 60 years (18 to 93 years), 55% male, and a median BMI of 26 kg/m2 (14 to 63 kg/m(2)). Thirty (10%) patients had cirrhosis. One hundred eighty-seven (61%) had previous abdominal operation. Median operative time was 163 minutes (30 to 433 minutes), with a median blood loss of 50 mL (10 to 900 mL). There were no deaths and 6 complications (2%): 2 wound infections, 1 failure to thrive, and 3 perihepatic abscesses. Readmission was required in 5 (1.6%) patients. Of the 268 malignancy cases, 25 (9%) were R1 resections. Of the 128 with superior segment resections (segments 7, 8, 4A, 2, and 1), there were 12 positive margins (9%) and 2 readmissions for abscess. CONCLUSIONS: Outpatient robotic hepatectomy in well-selected cases is safe (0 mortality, 2% complication, and 1.6% readmission), including resection in the superior or posterior portions of the liver that is challenging with nonarticulating laparoscopic instruments. (c) 2024 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.

BACKGROUND:This study aimed to assess the prognostic value of total tumor volume (TTV) for early recurrence (within 6 months) and overall survival (OS) in patients with colorectal liver metastases (CRLM), treated with induction systemic therapy followed by complete local treatment. METHODS:Patients with initially unresectable CRLM from the multicenter randomized phase 3 CAIRO5 trial (NCT02162563) who received induction systemic therapy followed by local treatment were included. Baseline TTV and change in TTV as response to systemic therapy were calculated using the CT scan before and the first after systemic treatment, and were assessed for their added prognostic value. The findings were validated in an external cohort of patients treated at a tertiary center. RESULTS:In total, 215 CAIRO5 patients were included. Baseline TTV and absolute change in TTV were significantly associated with early recurrence (P = 0.005 and P = 0.040, respectively) and OS in multivariable analyses (P = 0.024 and P = 0.006, respectively), whereas RECIST1.1 was not prognostic for early recurrence (P = 0.88) and OS (P = 0.35). In the validation cohort (n = 85), baseline TTV and absolute change in TTV remained prognostic for early recurrence (P = 0.041 and P = 0.021, respectively) and OS in multivariable analyses (P < 0.0001 and P = 0.012, respectively), and showed added prognostic value over conventional clinicopathological variables (increase C-statistic, 0.06; 95 % CI, 0.02 to 0.14; P = 0.008). CONCLUSION:Total tumor volume is strongly prognostic for early recurrence and OS in patients who underwent complete local treatment of initially unresectable CRLM, both in the CAIRO5 trial and the validation cohort. In contrast, RECIST1.1 did not show prognostic value for neither early recurrence nor OS.

Background:The outcomes of liver surgery worldwide remain unknown. The true population-based outcomes are likely different to those vastly reported that reflect the activity of highly specialized academic centers. The aim of this study was to measure the true worldwide practice of liver surgery and associated outcomes by recruiting from centers across the globe. The geographic distribution of liver surgery activity and complexity was also evaluated to further understand variations in outcomes.Methods:LiverGroup.org was an international, prospective, multicenter, cross-sectional study following the Global Surgery Collaborative Snapshot Research approach with a 3-month prospective, consecutive patient enrollment within January-December 2019. Each patient was followed up for 90 days postoperatively. All patients undergoing liver surgery at their respective centers were eligible for study inclusion. Basic demographics, patient and operation characteristics were collected. Morbidity was recorded according to the Clavien-Dindo Classification of Surgical Complications. Country-based and hospital-based data were collected, including the Human Development Index (HDI). (NCT03768141).Results:A total of 2159 patients were included from six continents. Surgery was performed for cancer in 1785 (83%) patients. Of all patients, 912 (42%) experienced a postoperative complication of any severity, while the major complication rate was 16% (341/2159). The overall 90-day mortality rate after liver surgery was 3.8% (82/2,159). The overall failure to rescue rate was 11% (82/ 722) ranging from 5 to 35% among the higher and lower HDI groups, respectively.Conclusions:This is the first to our knowledge global surgery study specifically designed and conducted for specialized liver surgery. The authors identified failure to rescue as a significant potentially modifiable factor for mortality after liver surgery, mostly related to lower Human Development Index countries. Members of the LiverGroup.org network could now work together to develop quality improvement collaboratives.

Background Consensus on resectability criteria for colorectal cancer liver metastases (CRLM) is lacking, resulting in differences in therapeutic strategies. This study evaluated variability of resectability assessments and local treatment plans for patients with initially unresectable CRLM by the liver expert panel from the randomised phase III CAIRO5 study. Methods The liver panel, comprising surgeons and radiologists, evaluated resectability by predefined criteria at baseline and 2-monthly thereafter. If surgeons judged CRLM as resectable, detailed local treatment plans were provided. The panel chair determined the conclusion of resectability status and local treatment advice, and forwarded it to local surgeons. Results A total of 1149 panel evaluations of 496 patients were included. Intersurgeon disagreement was observed in 50% of evaluations and was lower at baseline than follow-up (36% vs. 60%, p < 0.001). Among surgeons in general, votes for resectable CRLM at baseline and follow-up ranged between 0–12% and 27–62%, and for permanently unresectable CRLM between 3–40% and 6–47%, respectively. Surgeons proposed different local treatment plans in 77% of patients. The most pronounced intersurgeon differences concerned the advice to proceed with hemihepatectomy versus parenchymal-preserving approaches. Eighty-four percent of patients judged by the panel as having resectable CRLM indeed received local treatment. Local surgeons followed the technical plan proposed by the panel in 40% of patients. Conclusion Considerable variability exists among expert liver surgeons in assessing resectability and local treatment planning of initially unresectable CRLM. This stresses the value of panel-based decisions, and the need for consensus guidelines on resectability criteria and technical approach to prevent unwarranted variability in clinical practice.