The definition of textbook outcome (TO) for liver surgery in patients with intrahepatic cholangiocarcinoma (ICC) varies depending on the data and TO model utilized in the study. This study aimed to clarify the separate estimation of TO in relation to its negative predictors, using two validated TO models for ICC surgery. We assessed the rates of achieving TO and failure of TO for both models in liver resection. Independent predictors of non-TO were identified through logistic regression and validated using AUC estimation. TO was achieved in a similar proportion of patients across both models: 40% and 43%. The TO models did not differ in preoperative data affecting TO achievement. Independent predictors of non-TO for both models included tumor size > 10 cm,, open surgical approach, and biliary resection. TO achievement significantly differed among sub-groups that were homogeneous concerning the opposing values of the independent predictors, regardless of the TO model. The ratio of the frequency of negative predictors in the TO and non-TO groups, referred to as the TO coefficient, determines the likelihood of achieving TO given the presence of that predictor. Predictors were ranked by their negative impact on TO achievement, from the highest risk of TO failure (tumor size > 10 cm) to the lowest risk (open approach). Independent predictors of non-TO may improve the transparency of TO assessment and reduce biases related to unaccounted negative prognostic factors. The impact of these independent predictors on TO realization can be estimated and ranked using TO coefficient calculations.

Inferior vena cava (IVC) reconstruction is a complex procedure that, in selected cases, may be the only viable option for achieving complete oncologic resection. One such technique, the use of a peritoneal patch (PP) for IVC reconstruction, is beneficial but rarely reported. In this report, we present a successful case of IVC reconstruction using a PP during the surgical treatment of intrahepatic cholangiocarcinoma. The patient, a 60-year-old female, had an 80 × 77 × 72 mm mass located in segments I, IV, VII, and VIII, involving the IVC. After neoadjuvant chemotherapy and right liver deprivation, she underwent right hepatectomy combined with caudate lobe resection. During surgery, the anterior wall of the IVC was reconstructed using a PP, and the left portal vein was reconstructed with an end-to-end anastomosis. The total operative time was 570 minutes, with no intraoperative complications. The patient was hospitalized for 27 days, including five days in the intensive care unit. Postoperatively, she developed a Clavien-Dindo grade IIIb complication, consisting of gastroparesis, an abdominal collection with a low-output biliary fistula, pleural effusion requiring surgical drainage, and sepsis, which was successfully treated with antibiotics. At 40 months after surgery, the patient remains alive, with no evidence of tumor recurrence and a good quality of life. This case demonstrates that IVC reconstruction using a PP is a feasible alternative for achieving complete oncologic resection. Despite a high but manageable rate of postoperative morbidity, this approach enabled complete tumor resection and resulted in long-term survival.

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. 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. 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%). 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.

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. 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. 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). PG was associated with a lower incidence of grade B POPFs but higher rates of DGE, PPH, and in-hospital mortality.

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. 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. 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; I2 = 48%). 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.

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). 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. 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. 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.

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.

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.

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. 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). 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. 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.

Phase angle (PhA), as measured by bioelectrical impedance analysis, provides insights into hydration and nutritional status, making it a prognostic indicator of frailty. While low preoperative PhA has been linked to postoperative complications in cancer patients, its predictive value in individuals undergoing pancreaticoduodenectomy (PD) has not been thoroughly investigated. This study aims to evaluate the clinical utility of preoperative PhA in predicting postoperative complications for patients undergoing PD. Among 41 patients who underwent PD at Seoul National University Hospital between September and December 2024, 35 were included in the analysis after excluding 6 patients who had concomitant blood vessel or other organ resections. Patients were divided into low (Comprehensive Complication Index [CCI] ≤ 20) and high (CCI > 20) complication groups based on the CCI, derived from the Clavien-Dindo classification. The differences in PhA between the two groups were analyzed, and logistic regression was performed to assess the relationship between PhA and CCI. The mean PhA was significantly lower in the high-CCI group compared to the low-CCI group (5.7° vs. 6.7°, p = 0.025). Multivariate logistic regression analysis indicated that PhA (odds ratio: 0.17; 95% confidence interval: 0.04-0.68; p = 0.012) was an independent predictor of high CCI. A low preoperative PhA was associated with an increased risk of postoperative complications following PD. Preoperative PhA may serve as a valuable predictive indicator of postoperative complications after PD, enabling the identification of patients who could benefit from preoperative prehabilitation, including nutritional support.