Preoperative biliary drainage (PBD) is commonly used prior to pancreatoduodenectomy (PD), but its histologic effects on the extrahepatic bile duct are not well understood in humans. This study aimed to prospectively measure pericholedochal fibrosis (PCF) in PD specimens after plastic biliary stenting to assess its extent and clinical significance. Consecutive patients undergoing PD were divided into two groups: those who received PBD (n = 22) and non-drained controls (n = 24). Patients who had neoadjuvant chemotherapy were excluded to focus on stent-related effects. Common bile duct (CBD) specimens were analyzed using standardized Masson's trichrome staining. Digital morphometry quantified CBD dimensions, collagen area, and collagen density. Histologic markers were correlated with stent dwell time and surgical outcomes. PBD was linked to a substantial increase in PCF. Stented ducts showed significantly greater wall thickness (6,554 vs. 499 μm; p < 0.001), total collagen area (p < 0.001), and collagen density (p < 0.001) compared to controls. Fibrosis developed rapidly, becoming clearly evident by day 6, with no significant correlation between collagen burden and stent dwell time (median 10 days). Despite these pronounced histologic changes, operative time (230 vs. 230 minutes; p = 0.98) and postoperative complication rates did not differ significantly between the groups. Short-term PBD with plastic stents causes rapid, intense, and persistent PCF that stabilizes soon after stent placement. Although this fibrotic response did not negatively impact surgical outcomes at a high-volume center, the findings underscore the significant tissue remodeling triggered by stenting and advocate for the careful use of PBD.

Pancreaticoduodenectomy (PD) is the standard treatment for periampullary tumors, but it is technically challenging. Evidence directly comparing open, laparoscopic, robotic, and hybrid approaches is limited. This study conducts a network meta-analysis (NMA) to compare the perioperative and oncologic outcomes of open PD (OPD), laparoscopic PD (LPD), robotic PD (RPD), and hybrid PD. We searched PubMed, EMBASE, and the Cochrane Library for studies published between January 1994 and August 2024. We included randomized controlled trials and comparative observational studies that evaluated at least two PD approaches. Perioperative outcomes were the primary endpoints, while oncologic safety served as a secondary endpoint. A random-effects NMA was performed, establishing treatment hierarchies through ranking probabilities (PROSPERO ID: CRD420250365864). A total of 78 studies were included (5 randomized and 73 retrospective). RPD was associated with lower blood loss compared to OPD (mean difference [MD], -163.85 mL) and LPD (MD, -84.14 mL). Hospital stays were also shorter for RPD compared to OPD (MD, -2.50 days) and LPD (MD, -1.88 days). In contrast, OPD was the most time-efficient approach compared to LPD (MD, -77.61 minutes) and RPD (MD, -73.30 minutes). Mortality rates, severe complications, clinically relevant postoperative pancreatic fistula rates, and reoperation rates were comparable across all surgical approaches. In terms of oncologic safety, lymph node yield and R0 resection rates were similar for all modalities. While OPD is the most time-efficient approach, RPD provides significant advantages in reducing intraoperative blood loss and shortening hospital stays compared to both LPD and OPD.

Left lateral sectionectomy (LLS) is a commonly performed liver resection. The Rex-recess technique, an extrahepatic Glissonian approach through the umbilical fissure, provides earlier extrahepatic vascular control, potentially resulting in safer and faster resections. However, comparative data between these approaches is limited. This study aims to compare the Rex-recess technique with the standard technique for LLS regarding operative parameters, intraoperative blood loss, and postoperative outcomes. This retrospective cohort study included 48 consecutive adult patients who underwent open LLS at a tertiary hepatobiliary centre between January 2021 and November 2025. Patients were categorized based on the surgical technique used: standard technique (n = 25) and Rex-recess technique (n = 23). Primary outcomes assessed included operative time, blood loss, transfusion requirements, and postoperative complications. Secondary outcomes focused on selected early postoperative recovery parameters. Baseline demographics were comparable between groups. The Rex-recess technique significantly reduced operative time (90 ± 17.1 minutes vs. 162 ± 27.2 minutes; p < 0.0001) and intraoperative blood loss (80 ± 42.3 mL vs. 250 ± 67.2 mL; p < 0.0001).Other postoperative outcomes, including complication rates and length of hospital stay, were comparable between the two groups. The Rex-recess approach appears to be a feasible and anatomically sound technique for LLS, offering advantages in operative efficiency, such as reduced operative time and blood loss. However, due to the retrospective design and non-randomized allocation, these findings should be interpreted with caution. Further prospective studies are needed to validate these results.

Subtotal cholecystectomy is a salvage procedure when critical safety margins cannot be achieved in difficult cases. This study evaluated the impact of surgical approach and technique on short- and long-term outcomes. A retrospective review of 101 patients who underwent subtotal cholecystectomy between January 2010 and November 2024 was conducted. Patients were grouped by approach: laparoscopic (n = 42), open (n = 31), and conversion (n = 28). Techniques were classified as fenestrating or reconstituting. Complications were assessed using the Clavien-Dindo classification. Logistic regression identified risk factors, and Cox regression evaluated long-term outcomes. Intention-to-treat analysis was performed. The mean follow-up was 6.7 years. Morbidity was lower in the laparoscopic group (9.5%) than in the open group (45.2%) (p < 0.001). However, after adjustment for age, American Society of Anesthesiologists score, and emergency status, surgical approach was not an independent risk factor (adjusted odds ratio 1.54, p = 0.214). No significant differences were observed between fenestrating and reconstituting techniques. Five-year complication-free survival was 92.9% in the laparoscopic group and 74.2% in the open group (p = 0.018). No stone recurrence was observed. Subtotal cholecystectomy is a safe option in complex cases. Outcome differences are likely related to patient selection rather than technique. Technique selection should be based on intraoperative findings.

The most common cause of morbidity following pancreatoduodenectomy (PD) is the clinically relevant postoperative pancreatic fistula (CR-POPF). There is currently no universally accepted technique for pancreato-enteric anastomosis. This study aims to compare the Blumgart technique (B-PJ) with the modified Blumgart technique (mB-PJ). This is a retrospective study involving patients who underwent PD between January 2011 and December 2021. The primary endpoint was to compare the incidence of CR-POPF. Secondary endpoints included major morbidity, length of postoperative stay, rates of reoperation, hospital readmission, postoperative mortality, and predictors of CR-POPF. Propensity score matching (PSM) was employed to minimize potential selection bias. The study included 292 patients. After PSM, the incidence of CR-POPF was not significantly different between B-PJ and mB-PJ (18.9% vs. 15.8%, p = 0.566). No statistical differences were observed in the secondary endpoints. Independent predictors of CR-POPF included preoperative cholangitis (odds ratio [OR]: 4.906, 95% confidence interval [CI]: 1.440-16.713, p = 0.011), soft pancreas (OR: 4.259, 95% CI: 1.043-17.376, p = 0.043), and main pancreatic duct size ≤ 3 mm (OR: 5.229, 95% CI: 1.865-14.656, p = 0.002). This study did not demonstrate that mB-PJ is superior to B-PJ in reducing the incidence of CR-POPF. Factors such as soft pancreas, main pancreatic duct size, and preoperative cholangitis are identified as independent risk factors for CR-POPF.

Three-dimensional (3D) modeling is increasingly used in hepatobiliary surgery to enhance anatomical understanding and operative planning. However, its impact on oncologic outcomes remains uncertain. This study evaluated whether preoperative 3D liver models influence resection margin status and survival after hepatectomy for malignant disease. In this retrospective case-control study, 59 patients undergoing hepatic resection for malignancy between May 2018 and May 2023 were included. Patients were managed either with patient-specific 3D models (n = 31) or conventional imaging (n = 28). Predictors of R0 resection were analyzed using logistic regression, and overall survival (OS) and disease-free survival (DFS) were assessed using Cox proportional hazards models. R0 resection was achieved in 79.7% of patients, with no significant difference between groups (77.4% vs. 82.1%; p = 0.865). Bilobar tumor distributionadjusted odds ratio [OR] 0.05, 95% confidence interval [CI] 0.00-0.76; p = 0.039) and a higher albumin-bilirubin score (adjusted OR 0.06, 95% CI 0.00-0.46; p = 0.029) were independently associated with lower odds of achieving R0 resection. In multivariable analysis, the use of 3D models was independently linked to improved 2-year DFS (adjusted hazard ratio 0.47, 95% CI 0.24-0.92; p = 0.028). Tumor type affected recurrence rates, with hepatocellular carcinoma and other tumors showing a lower risk of recurrence compared to colorectal liver metastases. No significant differences in OS were found. Preoperative 3D modeling was not associated with higher R0 resection rates but was independently associated with improved 2-year DFS. Given the retrospective design and potential residual confounding, these findings should be interpreted cautiously and considered hypothesis-generating pending prospective validation.

Patients with hepatocellular carcinoma (HCC) and histologically confirmed F4 cirrhosis often have limited hepatic reserve, making major hepatectomy difficult. Although laparoscopic liver resection is increasingly performed, its perioperative safety in this setting remains unclear. This study compared laparoscopic and open partial hepatectomy in these patients using propensity score matching (PSM). Among 298 patients who underwent hepatectomy for HCC between 2006 and 2023, 112 with histologically confirmed F4 cirrhosis who underwent partial hepatectomy were included (laparoscopic, n = 60; open, n = 52). PSM was performed using previous liver resection, difficulty score, tumor size, tumor number, and platelet count, yielding 32 matched pairs. Outcomes included operative time, blood loss, transfusion requirements, complications, hospital stay, posthepatectomy liver failure (PHLF), R0 resection rate, and 30-day mortality. After matching, intraoperative blood loss was significantly lower in the laparoscopic group than in the open group (50 mL vs. 295 mL, p < 0.001). Operative time, transfusion rate, complication rate, R0 resection rate, and 30-day mortality were comparable between groups. Hospital stay was significantly shorter in the laparoscopic group (13 vs. 22 days, p < 0.001). Grade A PHLF occurred in one patient in the open group, with no significant between-group difference. In patients with HCC and histologically confirmed F4 cirrhosis, laparoscopic partial hepatectomy was associated with less blood loss and shorter hospital stay than open surgery, without increasing perioperative morbidity. It may be a safe option in carefully selected patients undergoing limited liver resection.

The effect of preoperative biliary drainage (PBD) on outcomes for pancreaticoduodenectomy (PD) patients with moderate jaundice (10-15 mg/dL) remains understudied. While PBD aims to improve hepatic function, it may increase morbidity due to infections. This study analyzed PDs performed between July 2022 and 2025. Patients with periampullary cancers and bilirubin levels of 10-15 mg/dL were included. We compared patients who underwent upfront PD (upfront surgery [UP] group) with those who received PBD (via endoscopic retrograde cholangiopancreatography or percutaneous transhepatic biliary drainage) regarding perioperative outcomes, morbidity, mortality, bile microbiology, antibiotic use, and costs. Among 92 PD patients, 40 met the inclusion criteria (UP = 16; PBD = 24). Baseline characteristics were comparable, except for higher bilirubin levels in the UP group (12.6 mg/dL vs. 1.35 mg/dL, p = 0.001). The PBD group exhibited a harder pancreatic texture (58.3% vs. 25.0%, p = 0.03), higher surgical site infections (SSIs) (70.8% vs. 18.7%, p = 0.001), and a greater incidence of positive bile cultures (75% vs. 25.0%, p = 0.001). Overall morbidity, Clavien-Dindo grade 3 complications, and 90-day mortality rates were similar between the groups. However, antibiotic costs were significantly higher in the PBD group (₹31,047 vs. ₹20,937; + 50%). In patients with moderate jaundice (10-15 mg/dL), upfront PD can be performed safely. Routine PBD offers no clinical benefit and is associated with higher rates of SSIs, bile contamination, and increased costs.

Total pancreatectomy with islet autotransplantation (TPIAT) is an irreversible intervention for selected patients with chronic pancreatitis, associated with significant morbidity and lifelong metabolic consequences. Given the benign nature of the disease, robust assessment, governance, and consent processes are ethically essential. Despite increasing global adoption, there is limited description of how there is limited description of how centres implement assessment and consent in routine practice. We describe a structured assessment and consent pathway for TPIAT developed over 30 years at a single UK hepatopancreatobiliary centre. The pathway is coordinated by a dedicated clinical nurse specialist (CNS) and delivered through a multidisciplinary team including surgery, gastroenterology, endocrinology, pain management, and psychology. A descriptive review of routinely collected clinical data and non-validated patient feedback obtained during standard care was performed to characterise key components of the pathway. Between 1994 and 2025, 97 patients entered the assessment pathway. Four did not complete assessment, and eight were deemed unsuitable following multidisciplinary review due to concerns regarding clinical appropriateness, metabolic reserve, or psychosocial readiness. Eighty-five patients proceeded to TPIAT. Progression through the pathway was iterative and consensus-driven, allowing any team member to pause evaluation. Key features included CNS-led continuity, repeated consultations, structured peer support, and multidisciplinary reassessment. Patient feedback suggested these elements improved understanding of procedural risks and long-term implications. This established, patient-centred assessment and consent framework represents a reproducible governance model for TPIAT in benign pancreatic disease and provides a practical reference for centres developing or refining TPIAT services.

Liver resection requires precise, millimetric decisions within highly variable, patient-specific vascular and biliary anatomy. As the complexity of procedures increases (such as in major or extended hepatectomies, central lesions, and borderline future liver remnant scenarios), reliance on "2D cognition" can heighten the risk of planning errors and postoperative complications. This study aims to synthesize the role of 3D liver technologies, including digital visualization and planning, 3D printing, and intraoperative navigation (such as augmented reality and mixed reality), as a decision-making pipeline. This is a narrative, question-driven review of clinically relevant studies focused on liver resection workflows that utilize 3D visualization/planning, 3D printing, or intraoperative navigation. Across diverse studies, the most significant benefits of 3D planning are observed in anatomically complex or borderline cases. These benefits primarily enhance decision transparency and process-level endpoints (e.g., mapping, plan modifications, intraoperative orientation). However, consistent effects on morbidity and liver-specific outcomes are limited due to confounding factors and inconsistencies in endpoints. Augmented reality and mixed reality navigation face challenges related to registration stability and liver deformation, making uncertainty management and local accuracy reporting crucial. 3D printing appears most beneficial as a selective tool for high-stakes anatomy, as well as for communication and education, with feasibility influenced by time and cost considerations. "3D" should be assessed as an end-to-end measurement pipeline with explicit error budgets. Future studies should prespecify decision endpoints, standardize outcome definitions, and report task-relevant accuracy, particularly concerning navigation and critical biliary/vascular structures.