We present our standardized technique for laparoscopic right hepatectomy, utilizing a pre-placed endoscopic nasobiliary drainage catheter to enhance intraoperative cholangiography and ensure the safe division of the right Glissonean pedicle. This technique is particularly beneficial in cases of giant hepatic hemangioma, where limited working space and distorted hilar anatomy can complicate biliary and vascular management. Key steps in the procedure include: preoperative planning with contrast-enhanced computed tomography and endoscopic retrograde cholangiopancreatography, selective hepatic arterial embolization (transcatheter arterial embolization) when necessary, appropriate patient positioning and port placement, an extrahepatic Glissonean approach, cholangiographic verification of the right hepatic duct, staged control of the right portal vein following initial parenchymal transection, and hemostatic parenchymal transection. The patient’s postoperative course was uneventful, and the patient was discharged on postoperative day 9 without complications.

Background: s/Aims: This study evaluated the feasibility and outcomes of surgical treatment for metachronous periampullary carcinoma following curative resection of primary extrahepatic bile duct cancer. Methods: A retrospective review was conducted of seven patients who underwent pancreaticoduodenectomy (PD) for metachronous periampullary cancer after prior curative surgery for extrahepatic bile duct cancer. Results: The mean age at the second surgery was 66.7 years (range, 43–81 years). Initial malignancies included three hilar cholangiocarcinomas, one middle bile duct cancer, and three gallbladder cancers. Subsequent primary tumors consisted of three distal bile duct cancers, three pancreatic head cancers, and one duodenal cancer. The mean interval between the first and second cancers was 47 months (range, 13–121 months). No perioperative deaths occurred. Postoperative complications developed in three patients (42.9%):chyle leakage (Clavien–Dindo grade II) in two (28.6%) and a grade C postoperative pancreatic fistula requiring reoperation (grade IIIb) in one (14.3%). Both chyle leaks were managed conservatively. During follow-up, four patients died of recurrence at 5, 12, 19, and 24 months postoperatively. One patient underwent video-assisted thoracoscopic surgery for pulmonary metastasis 2 months after PD and remains alive 22 months later without recurrence. Two patients are disease-free at 38 and 92 months of follow-up. Conclusions PD for second primary periampullary cancer after resection of extrahepatic bile duct cancer appears feasible and potentially effective. Although no perioperative mortality occurred, major complications were observed. Larger studies are needed to confirm these preliminary findings.

Background: s/Aims: The role of surgery for pancreatic ductal adenocarcinoma (PDAC) with synchronous liver metastases remains controversial. Previous studies assessing the outcomes of combined surgery for primary PDAC and liver metastases have been limited by the inconsistent application of neoadjuvant chemotherapy (NAC). Methods: We identified patients with PDAC and fewer than three liver metastases who received at least six months of NAC and underwent simultaneous pancreas and liver resection between January 2018 and March 2023 at a single institution. Additionally, we queried the National Cancer Database (NCDB) from 2010 to 2019 to identify patients with synchronous metastatic PDAC to the liver who received NAC before simultaneous resection, serving as a comparison group. Results: Ten patients met the inclusion criteria for the institutional case series, with seven ultimately undergoing simultaneous resection. Among 224 patients in the NCDB who underwent simultaneous pancreas and liver resection, 70 patients (31.2%) received NAC.After a median follow-up of 59 months in the institutional cohort, five patients experienced recurrence, resulting in a median disease-free survival of four months (95% confidence interval [CI] 3, not reached). After controlling for confounding factors in the NCDB cohort, the administration of NAC was associated with improved survival (hazard ratio: 0.44, 95% CI 0.29–0.65, p < 0.001) compared to those who underwent upfront surgery. Conclusions Neoadjuvant therapy followed by simultaneous liver and pancreas resection for metastatic PDAC is safe and feasible, and it may provide a survival benefit in carefully selected patient populations.

Situs inversus totalis is a rare congenital anomaly where thoracic and abdominal organs are completely reversed in mirror-image orentation. While it does not preclude transplantation, it presents significant technical challenges, especially in liver transplantation, due to the altered orientation of vascular and biliary structures. We present a case involving a 50-year-old man with end-stage renal disease and advanced cholestatic cirrhosis. His model for end-stage liver disease score was 26, qualifying him for combined liver-kidney transplantation. A donor with SIT became available, and pre-donor evaluation confirmed complete SIT with typical vascular and biliary anatomy. The donor liver weighed 900 g. During orthotopic positioning, the alignment was unfavorable, necessitating the graft to be implanted in a retroversus orientation to restore optimal anatomical relationships. Vascular reconstructions included an endto-side piggyback cavocaval anastomosis, an end-to-end portal vein reconstruction, and an arterial anastomosis between the donor common hepatic artery and the recipient’s right hepatic artery originating from the superior mesenteric artery. Biliary continuity was established through duct-to-duct anastomosis. Subsequently, kidney transplantation was performed in the right iliac fossa using the donor’s right kidney. No blood transfusions were needed, and the postoperative recovery was smooth. Both grafts functioned normally, and the patient was discharged on postoperative day 12. At the 9-month follow-up, liver and kidney functions remained excellent.Retroversus implantation enabled successful combined liver-kidney transplantation using a donor liver from a patient with SIT. This case underscores the necessity for meticulous planning, intraoperative adaptability, and technical modifications to ensure safe transplantation in anatomically challenging situations.

Background: s/Aims: Postoperative pancreatic fistulas (POPF) remain a major cause of morbidity and mortality following pancreatoduodenectomy (PD). Pancreatogastrostomy (PG) and pancreatojejunostomy (PJ) are the two most commonly used reconstruction techniques, yet evidence favoring one over the other is inconclusive. This study evaluates postoperative outcomes following open PD at a single institution that transitioned from PG to PJ as the preferred reconstruction method. Methods: This retrospective comparative study included patients who underwent PD between April 2005 and August 2022. Of 757 patients identified, 522 met the inclusion criteria. Propensity score matching (PSM) was performed to adjust for clinically relevant covariates. Primary endpoints were clinically relevant (CR) POPF (grade B/C) and Clavien–Dindo (CD) grade ≥ 3 POPFs. Secondary outcomes included post-pancreatectomy hemorrhage (PPH), delayed gastric emptying (DGE), systemic complications, length of hospital stay, and mortality. Results: Overall, CR-POPF and CD grade ≥ 3 POPFs occurred in 21.3% and 8.0% of patients, respectively. Thirty-day and in-hospital mortality rates were 3.1% and 4.2%. After PSM, 368 patients (184 PG and 184 PJ) were analyzed. Grade B POPFs were more frequent following PJ than PG (24.5% vs. 15.8%, p < 0.001). Although CR-POPF and CD grade ≥ 3 POPFs were numerically higher in the PJ group, differences were not statistically significant. In contrast, DGE, PPH, and in-hospital mortality were significantly higher following PG (37.0% vs. 25.0%, p = 0.025; 16.3% vs. 8.7%, p = 0.025; and 7.6% vs. 2.7%, p = 0.049, respectively). Conclusions PG was associated with a lower incidence of grade B POPFs but higher rates of DGE, PPH, and in-hospital mortality.

Background: s/Aims: To evaluate the impact of unplanned conversion to open surgery on resection margin status and postoperative complications in patients undergoing minimally-invasive resection of colorectal liver metastases (CRLM). Methods: This study performed a proportion meta-analysis and meta-regression using random-effects modelling in accordance with PRISMA guidelines. Studies with at least 15 patients that reported conversion to open surgery in individuals receiving minimally-invasive CRLM resection were included. The association of unplanned conversion with postoperative outcomes was analyzed. Results: Eighty-six studies encompassing 18,138 patients were analyzed. The overall conversion rate was 5.8% (95% CI 5%–6.6%).Conversion was associated with improved R0 resection rates (coefficient: 2.167, p < 0.001) but was also linked to increased postoperative mortality (coefficient: 7.585, p = 0.001) and morbidity (coefficient: 1.737, p = 0.003); there was no significant impact on 5-year overall survival (coefficient: 0.700, p = 0.989) or 5-year disease-free survival (coefficient: –72.900, p = 0.157). Specifically, conversion due to oncological concern was associated with higher rates of R0 resection (coefficient: 0.638, p = 0.005); conversion resulting from iatrogenic injuries was associated with lower R0 resection rates (coefficient: –1.478, p < 0.001); conversion for technical difficulties was associated with lower postoperative morbidity (coefficient: –0.380, p = 0.006). Conclusions Unplanned conversion to open may carry prognostic and oncological implications for minimally-invasive resection of CRLM. Although conversion due to bleeding and iatrogenic injury is routinely considered, conversion prompted by technical difficulties or oncological concerns should not be considered failure, as it may be associated with improved patient outcomes.

Background: s/Aims: Hepatic artery pseudoaneurysm (HAP) is a condition associated with high mortality rates when untreated. Current literature lacks comprehensive understanding of complication rates and optimal treatment strategies. This study aims to analyze the etiology, technical success, and complication rates associated with endovascular and percutaneous management of HAP. Methods: A retrospective analysis was conducted, examining data on demographics, comorbidities, etiology, and embolic agents. A comparative analysis of hemoglobin levels, liver function tests, and renal function tests was performed before and 24–48 hours after the procedure. Results: The study included 49 patients (71% males) with a mean age of 46.44 (± 15.88) years. The common etiologies were post-operative complications (36.7%) and blunt abdominal trauma (26.5%). The right hepatic artery (RHA) was the most frequently involved site (57%). Endovascular embolization involved the use of coils, glue, and stent grafts, while percutaneous embolization was performed in six cases. The technical success rate for the endovascular approach was 97.6%, compared to 33% for the percutaneous approach. Hemoglobin levels stabilized post-procedure (mean post-procedure 8.9 g/dL vs. 7.9 g/dL at presentation), indicating effective hemostasis.Post-procedural complications included transient elevation of liver enzymes (22.4%), hepatic abscess (4.1%), and cholangitis (2.0%). Conclusions HAP is primarily caused by iatrogenic injury or blunt abdominal trauma, with a predilection for the RHA. Endovascular therapy proves to be a safe and effective treatment for this life-threatening condition. Although high technical success rates are achievable, the potential for ischemic complications necessitates a tailored treatment approach and the implementation of prophylactic measures when indicated.

Background: s/Aims: Portal vein embolization (PVE) and Yttrium-90 (Y-90) radioembolization are used to induce liver hypertrophy, increasing future liver remnant volume and reducing the risk of post-resection liver failure. This systematic review compares the effectiveness of PVE and Y-90 radioembolization in promoting liver hypertrophy in patients undergoing liver resection. Methods: A systematic review was conducted in accordance with PRISMA guidelines. PubMed, Embase, Cochrane, and Web of Science were searched for studies published between January 2000 and August 2023. Studies comparing PVE and Y-90 radioembolization with respect to liver hypertrophy were included. Risk of bias was assessed using the Newcastle–Ottawa Scale. Pooled mean differences were calculated using an inverse-variance random-effects model. Results: Of 1,965 studies identified, three retrospective cohort studies met inclusion criteria, comprising 125 patients. Among these, 67.3% underwent PVE and 32.7% received Y-90 radioembolization. Hepatocellular carcinoma was the most common diagnosis (55.9%), followed by metastatic disease (32.3%) and cholangiocarcinoma (11.8%). PVE was more commonly used as a preoperative strategy for liver resection, while Y-90 radioembolization was primarily employed for palliative intent. One study reported greater hypertrophy with Y-90 compared to PVE (63% vs. 36%); however, hypertrophy was assessed over a longer interval (150 vs. 30 days). In pooled analysis, PVE was associated with significantly greater hypertrophy (mean difference 23.75%; 95% CI 12.02–35.48; p < 0.0001; I 2 = 48%). Conclusions Evidence directly comparing PVE and Y-90 radioembolization for liver hypertrophy remains limited. While pooled results favor PVE, procedure selection should be individualized based on clinical context.

Extensive porto-mesenteric thrombosis presents a significant challenge in liver transplantation and was previously considered a contraindication. However, advancements in surgical techniques have made liver transplantation feasible. For optimal allograft function, adequate portal flow is crucial, as it generates shear stress that stimulates regeneration. In such cases, portal inflow options include the left renal vein (reno-portal anastomosis; RPA), the inferior vena cava (cavo-portal hemi-transposition; CPHT), any patent splanchnic territory, portal vein arterialization, or multi-visceral transplantation. Among these, CPHT and RPA are the most commonly performed. Generally, CPHT is used in pediatric liver transplantation; however, it is rarely reported in adult living donor liver transplantation (LDLT) due to technical challenges. In this report, we describe our technical modifications to CPHT and present the results in two patients with extensive porto-mesenteric thrombosis who underwent LDLT.

Background: s/Aims: The benefits of nasogastric intubation after pancreaticoduodenectomy are not well understood, and it remains unclear which patients may need nasogastric intubation in the immediate postoperative period. This study evaluated the effectiveness of nasogastric intubation following pancreaticoduodenectomy and identified factors influencing the reintubation rate. Methods: We conducted a retrospective case-control cohort study involving adult patients who underwent pancreaticoduodenectomy for either benign or malignant periampullary disease, with a 90-day follow-up. Patients were divided into two groups: the nasogastric tube (NGT) was removed at the end of the procedure (NGT-removed group, n = 110; case group) or retained during the postoperative recovery (NGT-retained group, n = 100; control group). Results: The overall postoperative complication rate (grades I–IVb) was 40.4%. The only significant difference between the groups was a higher incidence of nausea and vomiting in the NGT-removed group (p = 0.02). Additionally, 14.8% of patients required NGT reinsertion postoperatively. No preoperative or intraoperative factors were found to influence the NGT reinsertion rate. Although patients requiring reinsertion experienced a higher rate of postoperative complications, no factor remained significant in the multivariate analysis. Conclusions There were no significant differences in clinical outcomes, reinsertion rates, or postoperative complications between the two groups, indicating that the removal of the NGT after pancreaticoduodenectomy is safe. However, univariate analysis revealed that postoperative complications significantly affected the need for NGT reinsertion, suggesting that nasogastric decompression may be crucial for patients at high risk for complications.