Abstract Purpose To describe the technique and evaluate the safety and clinical efficacy of CT-guided thermal ablation for postoperative isolated bile leakage (IBL) in patients with disconnected bile ducts. Materials and Methods This retrospective study included 14 patients with postoperative IBL following liver resection between 2016 and 2024. All patients underwent CT-guided radiofrequency ablation (RFA) as treatment for IBL. Technical success was defined as appropriate coverage of the leakage site on post-ablation CT. Clinical success was defined as cessation of IBL; time to leak cessation was recorded accordingly. Total percutaneous biloma drainage time and peri-/post-interventional complications were evaluated accordingly. Results Technical success was achieved in all ablation procedures with no major adverse events. Clinical success was observed in 93% ( n = 13) of patients. One patient experienced recurrence of IBL within 30 days. Median total drainage time was 33.5 (IQR 20–62) days. The median time to leak cessation after RFA was 4.5 (IQR 4–6) days. Conclusion CT-guided thermal ablation appears to be an effective and safe treatment option for postoperative IBL, helping to reduce the duration of drainage therapy. Graphical Abstract

Conventional umbilical access can be time-consuming, surgically challenging due to inadequate 'Critical View of Safety' and pneumoperitoneum maintenance for high body mass index (BMI) patients undergoing laparoscopic cholecystectomy (LC). The aim of the study is to assess the feasibility, safety and outcome of our modified access for patients of BMI ≥30. A prospective study of 1762 consecutive patients undergoing LC in a large district general hospital (2007-2023) that included age, sex, BMI, American Society of Anesthesiologists (ASA), grade of operation with stay and complications were analysed. Group A: Veress needle pneumoperitoneum through Palmer's point. After 2 L (minimum) insufflations, an optical port was introduced at the intersection of two imaginary lines: A 15-cm oblique line starting from where the right mid-clavicular line cuts the right lower costal margin and directed medially meeting the other vertical line running 3 cm to the right of midline. Remaining 3 ports at standard positions (10 mm epigastric port [I] at or just right of midline below the xiphoid process, 5 mm port [II] at the midclavicular line below the costal cartilage and another 5 mm port [III] between 5 cm and 10 cm lateral to port II) as used in LC. Group B (BMI <30): Conventional umbilicus entry followed by 3 standard remaining ports for LC (as above). Group A: 549 with female: male 4:1, the median of age 49 (16-83) years, BMI 36 (30-65), ASA 2 (1-3), Grade 1 (1-4), operating time 50 (15-200) min and post-operative (PO) stay 0 (0-15) day. One conversion, 2 bile leaks, 5 collections and 4 wound infections. Group B: 1213 with female: male 3:1, the median of age 53 (16-89) years, BMI 26 (17-29), ASA 2 (1-3), Grade 1 (1-4), operating time 45 (15-240) min and PO stay 0 (0-12) day. Our modified abdominal access is quick and safe that maintains sustained pneumoperitoneum and provides an excellent 'Critical view of Safety' for obese patients undergoing LC with a good outcome.

BackgroundSubtotal cholecystectomy (STC) is increasingly used as a safe technique for managing difficult gallbladders to reduce the risk of common bile duct (CBD) injury. However, techniques and outcomes vary across institutions, and standardised reporting remains limited.ObjectiveTo evaluate peri-operative and post-operative outcomes following STC at a single tertiary centre and to explore pre-operative factors associated with the need for STC, including the frequency of previous gallstone-related admissions and radiologic markers such as impacted infundibular or neck stones, thickened or contracted gallbladder, and imaging features suggestive of a frozen Calot’s triangle.MethodsRetrospective cohort study of consecutive patients undergoing STC between January 2021 and January 2024. Data included demographics, indications, operative technique (fenestrating vs. reconstituting), intra-operative findings, complications, and long-term biliary outcomes. The primary endpoint was clinically significant bile leak; secondary outcomes were reoperation, endoscopic retrograde cholangiopancreatography (ERCP) requirement, readmission, and mortality.ResultsThirty-nine patients underwent STC (97% laparoscopic, 3% open). Median age 49 years with a mean BMI of 39 kg/m2. Bile leak occurred in 2.6% (n = 1), reoperation 0%, ERCP 2.6% (n = 1), readmission 0%, and mortality 0%.ConclusionsSTC offers a safe alternative to total cholecystectomy in complex cases, though bile leak remains an important morbidity. Technique type and intra-operative factors influence outcomes, highlighting the need for standardised approaches and careful case selection.

BackgroundThere has been a shift in the management of choledocholithiasis from laparoscopic common bile duct exploration to endoscopic retrograde cholangiopancreatography. This has led to an increase in hospital length of stay, costs, and specifically for rural hospitals, transfer to a tertiary center for ERCP. Given this shift of choledocholithiasis management to advanced GI endoscopists, general surgery residents are rarely performing laparoscopic transcystic common bile duct explorations.MethodsA retrospective study of 69 consecutive laparoscopic transcystic common bile duct explorations (LCBDE) performed by 2 general surgeons in a rural community over 5years between 2017 and 2022. Primary outcomes included successful duct cannulation, successful stone clearance, instruments used, operative time, and significant complications (pancreatitis, bile leak, bleeding, bile duct injury). Specific technique for laparoscopic transcystic common bile duct exploration is outlined in Appendix 1.ResultsThere was a median age of 54years (Range 17-91). There was successful cannulation in 97% and successful stone clearance in 82% of cases. In the vast majority of cases only a guide wire and biliary balloon dilation catheter were utilized to perform the procedure. Median operative time for laparoscopic cholecystectomy with cholangiogram was 40minutes. Median operative time for laparoscopic cholecystectomy with cholangiogram and transcystic common bile duct explorations was 64minutes (Range 39-168). Therefore, the median time added by performing LCBDE was 24minutes There were no complications during laparoscopic transcystic common bile duct explorations.ConclusionsLaparoscopic transcystic common bile duct exploration can be safely, efficiently, and successfully performed with 0.035-inch Roadrunner PC guidewire, TAUT intraducer and an Advance Biliary Balloon Catheter. In order to shift the management of choledocholithiasis back to the general surgeon to decrease the length of stay and cost, there needs to be a change at the residency training level.

Background and Study Aim A delay or absence of follow-up after luminal or pancreatobiliary stent placement can lead to adverse events. Few studies have investigated patient factors that impact compliance. The aim of the study is to identify patient-related predictors of compliance and non-compliance for luminal or pancreatobiliary stent removal at a single center. Methods Patients who underwent EGD, EUS, and/or ERCP with temporary stent placement for disease from March 2020 to March 2024 were included. Compliance was defined as stent removal or imaging confirming stent passage within 6 months (plastic stents or any cystgastrostomy stents) or 12 months (metal biliary stents) of the index procedure. Social and demographic risk factors potentially associated with stent removal and non-compliance were analyzed. Results One hundred fifty-one cases fit the inclusion criteria, of which 118 involved compliant patients (78%) and 33 (22%) involved non-compliant patients. The time to stent removal was 57 ± 43 days in the compliant group and 324 ± 156 days in the non-compliant group (p&lt;0.001). Common procedure indications included pancreatitis-related complications (n=61), biliary obstruction (n=55), and bile leak (n=35). Predictors of non-compliance included male sex (0.047), history of drug use (p=0.033), and the absence of a working phone number (p=0.017) or email address (p=0.003), electronic medical record access (p&lt;0.001), or primary care provider (p=0.034) before the procedure. Conclusions Patient-specific risk factors for non-compliance of stent removal were identified. Patients with such risk factors may require extra education and communication efforts.

Composite endpoint for liver and colon simultaneous surgery: a proposed approach to reduce sample size of future clinical trials.

Duodenum-preserving pancreatic head resection in 1063 patients for benign, premalignant cystic, and neuroendocrine neoplasms - Short-term surgical outcomes and risk of recurrence - Results of a systematic review.

BackgroundRecent improvements in pancreatic surgery outcomes have highlighted the relevance of comprehensive quality measures, including textbook outcome. The aim of this study was to evaluate textbook outcome in patients with pancreatic neuroendocrine tumours undergoing surgical resection.MethodsAll patients undergoing surgery for pancreatic neuroendocrine tumours between 2010 and 2023 were included. Textbook outcome was defined as the absence of severe morbidity (Clavien–Dindo grade ≥ III), pancreatic fistula, bile leakage, haemorrhage, readmission, and no death. Logistic regression analysis was used to identify risk factors and Kaplan–Meier survival analysis to compare disease-free and overall survival.ResultsA total of 622 patients underwent surgery for pancreatic neuroendocrine tumours. Major morbidity occurred in 192 patients (30.9%) with an in-hospital mortality rate of 2.6% (16 patients). Rates of postoperative pancreatic fistula, haemorrhage, and readmission were 21.5, 6.4, and 10.3% respectively. Overall, a textbook outcome was achieved in 399 patients (64.1%), with a higher rate after organ-sparing versus formal resections (89 (74.8%) versus 310 (61.6%); P = 0.008). Risk factors for non-textbook outcome were older age (odds ratio 1.52, 95% confidence interval 1.05 to 2.20; P = 0.028), higher body mass index (odds ratio 1.61, 95% CI 1.15 to 2.25; P = 0.006), American Society of Anesthesiologists grade ≥ III (odds ratio 1.63, 95% CI 1.14 to 2.35; P = 0.008), and longer duration of surgery (odds ratio 1.69, 95% CI 1.17 to 2.45; P = 0.006). Patients with a textbook outcome had higher 5-year rates of disease-free (73 versus 67%; P = 0.025) and overall (88 versus 78%; P < 0.001) survival than those with a non-textbook outcome. This effect was confirmed in patients with non-functioning pancreatic neuroendocrine tumours (overall survival: 85 versus 77%; P = 0.003). In multivariable analysis, textbook outcome remained an independent predictor of survival.ConclusionA textbook outcome was achieved in most patients undergoing pancreatic surgery for pancreatic neuroendocrine tumours and was associated with improved long-term survival. Textbook outcome may serve as a quality control and prognostic indicator in surgery for pancreatic neuroendocrine tumours.

Prospective, randomized, controlled clinical study on single-incision laparoscopic cholecystectomy: an analysis of 449 cases from a single center.

Impact of corticosteroids on postoperative outcomes after hepatopancreatobiliary surgery.

Multi-Port Laparoscopic Versus Single-Site Robotic with DaVinci Xi® Elective Cholecystectomy in Adolescents: A Single Center 5-Year Review.

Anatomical liver resection along the intersegmental plane provides oncological advantages for primary liver malignancies and may reduce complications such as blood loss and postoperative bile leakage. In left lateral sectionectomy (LLS), the falciform ligament and umbilical fissure are conventionally regarded as landmarks; however, tertiary branches from the dorsal and cephalic sides of the portal umbilicus (P4dor) often annulate the left lateral region of the falciform ligament. We propose a novel LLS technique using an extrahepatic Glissonean approach combined with indocyanine green (ICG) fluorescence. To preliminarily investigate the P4dor territory, protocol-based dynamic computed tomography images of 128 patients scheduled for hepatobiliary and pancreatic surgery were analyzed. The safety and efficacy of the technique were assessed using robotic, laparoscopic, and open LLS. The Glissonean pedicles of segments 2 and 3 were isolated, P4dor boundaries delineated under ICG guidance, and the parenchyma transected along the demarcation line to preserve the P4dor region. P4dor was identified in 91.4% of cases, with a mean of 1.4 branches, an annular volume of 21.7 ml (2.1%), and a mean distance of 15.9 mm between the left border of the P4dor territory and the portal umbilicus. In all three surgical cases, the P4dor boundaries were clearly delineated and preserved. No postoperative complications occurred. This LLS technique is simple, feasible for minimally invasive surgery, and enables reproducible anatomical resection by clarifying the P4dor demarcation. It may also facilitate adequate margins in biliary tumors while preserving functional liver parenchyma.

Background and Objectives: Bile leak is a common complication after hepatopancreatobiliary surgery, requiring timely management to prevent life-threatening outcomes. Endoscopic retrograde cholangiopancreatography (ERCP) is essential in treatment, but large data concerning optimal timing and technique selection are unavailable. This study evaluates whether the timing of ERCP influences healing and if different bile duct injuries affect outcomes. Materials and Methods: Data from a prospectively maintained database over 25 years (2001–2025) included 176 patients (M/F: 91/85, mean age 62) undergoing ERCP for bile leaks. Results: Most leaks followed cholecystectomy (n = 143, 81.5%). The median time from leak to ERCP was 7 days. Ten patients (5.7%) had complete common bile duct (CBD) transection—considered major leaks—requiring surgery. Among the 166 minor leaks, the cystic duct stump (40.1%) was the most common injury site, followed by the CBD (24.1%) and the gallbladder bed (15.4%). Healing occurred in 90.6%. Stent placement improved healing rates (93.9% vs. 75.9%, p = 0.007), with no difference between pig-tail and (Amsterdam) straight plastic stents (90% vs. 96%, p = 0.267). Retained CBD stones or CBD strictures did not affect outcomes. Leaks from the cystic duct stump had a 96.9% resolution rate, whereas gallbladder bed leaks healed in 88%. The median healing time was 2 days, unaffected by stent placement or ES alone (p = 0.842), but later ERCP correlated with longer healing (RR: 0.362, p &lt; 0.001). Following a right aberrant bile leak, the time for healing was longer than in leaks from other sites. Conclusions: ERCP with stenting remains the first-line approach for minor bile leaks. Early ERCP accelerates healing, emphasizing the importance of prompt intervention.

BACKGROUNDSurgery and percutaneous radiological methods [puncture, aspiration, injection, re-aspiration (PAIR)] are the current invasive treatment strategies for patients with hepatic hydatid cyst (HHC). Biliary leak is a common complication in patients who underwent these treatments of HHC. Bile leak should be treated effectively as uncontrolled biliary fistula may lead to life-treating conditions such as severe cholangitis, intraabdominal abscesses and septicemia. Endoscopic retrograde cholangiopancreatography (ERCP) has become the main treatment of post-interventional biliary fistula.AIMTo evaluate the efficacy and safety of ERCP in the management of biliary fistula following HHC-related surgery or PAIR.METHODSWe evaluated data of patients who developed bile leakage following HHC-related interventions from endemic area during the period of March 2017 and February 2025. We included 88 patients (50 female, 57%) with a median age of 33 years (range: 8-83 years) at the time of ERCP. Bile leak occurred following surgery in 72 (82%) patients and after PAIR in 16 (18%) patients. Low-grade leakage (< 400 mL/day) was identified in 46 (52%) patients.RESULTSInitial mode of ERCP was endoscopic sphincterotomy (ES) with biliary drainage (plastic stent or nasobiliary drain) in 73 (83%) patients and ES alone in remaining 15 (17%) patients. Six patients who initially treated by ES alone had persistent fistula and underwent repeat ERCP with stent placement. ERCP type (ES + biliary stenting) and fistula flow rate (< 400 mL/day) were significantly associated with 20-days complete closure of the fistula [P = 0.020; odds ratio (OR) = 5.27, 95% confidence interval (95%CI): 1.30-21.37] and (P = 0.008; OR = 3.43, 95%CI: 1.37-8.55), respectively. ERCP-related complications were mild pancreatitis in 5 (5.9%) patients and minor bleeding in 4 (4.7%) patients and mild-moderate cholangitis in 4 (4.7%) patients.CONCLUSIONThis case based-study from endemic area demonstrates that ERCP is highly effective and safe for managing bile leakage following both surgery and PAIR. ES + biliary stenting seems better mode of ERCP procedure.

Background Postoperative nutritional support strategy after pancreaticoduodenectomy (PD) remains controversial. This retrospective study aims to evaluate early enteral nutrition (EEN) combined with supplemental parenteral nutrition (SPN) vs. parenteral nutrition (PN) as postoperative nutritional support, focusing on early clinical outcomes and postoperative complications in patients who underwent PD. Methods Clinical data from consecutive patients who underwent PD between January 2022 and July 2024 were collected and analyzed in this retrospective study. The primary outcome was the incidence of postoperative complications. The secondary outcomes included specific postoperative complications, such as delayed gastric emptying (DGE), bile leak (BL), chyle leak (CL), acute pancreatitis (AP), postpancreatectomy hemorrhage (PPH), and infectious complications, compared between the two groups. A propensity score-matched (PSM) analysis was performed to balance baseline confounders between the groups. Results According to perioperative nutritional protocols, 248 patients were included and divided into the EEN + SPN group ( n = 116) and the PN group ( n = 132). After PSM, baseline characteristics were balanced between the EEN + SPN group ( n = 59) and the PN group ( n = 59). No statistically significant differences were observed in the incidence of complications between the two groups, either before or after PSM (all p &amp;gt; 0.05). Before PSM, the overall incidence of severe postoperative complications was 10.1%. The EEN + SPN group demonstrated a significantly lower incidence of severe complications compared to the PN group both before and after PSM ( p &amp;lt; 0.05). Analysis of secondary outcomes (which included a comparative analysis of detailed complications) revealed no significant differences between the groups. Conclusion In conclusion, this study demonstrates that for patients at nutritional risk following PD, EEN + SPN is a safe and feasible nutritional support strategy and is associated with a significant reduction in the incidence of severe complications.

Background: Laparoscopic cholecystectomy (LC) is the gold standard surgical treatment of cholelithiasis. However, this surgery has its own known complications. Assessment of patients with preoperative MRCP for anatomical anomaly in biliary tree and common bile duct stones (CBDs), can prevent intraoperative and post operative complications. Methods: Authors conducted retrospective randomized study at Kota Heart Hospital, Kota, Rajasthan between January 2014 and December 2024. Patients with the presence of symptomatic cholecystolithiasis undergoing LC without signs (i.e., jaundice) of cholestasis were included in our study. Patients were divided into two groups; Group I included 696 patients in whom pre-operative MRCP followed by laparoscopic cholecystectomy was done . Group II included 290 patients who underwent laparoscopic cholecystectomy and routine MRCP was omitted in their pre-operative workup. We measured intraoperative biliary injury and the incidence rate of postoperative complications in this study. Results: The Study showed that all patients in Group I revealed smooth post-operative period and no incidence of residual CBD calculi. In group II, 9 patients developed early bile leakage and one developed jaundice after 7 months. Preoperative MRCP was able to diagnose biliary radicles abnormalities in 8 patients (1.1%) of group 1. Also the course of cystic duct was diagnosed tortuous in 29 cases (4.1%) of group 1. Conclusions: Preoperative MRCP helps in visualization of the extrahepatic biliary tree and in identifying CBD stones. This provides surgeon information about possible anatomical variations. Which leads to decrease in incidence of intraoperative complications and residual CBD stones.

This study aimed to compare the impact of argon plasma coagulation (APC) and electrosurgical knife (EK) in sealing the hepatic transection surface of patients undergoing curative resection for hepatocellular carcinoma (HCC). This single-center retrospective study was performed in the department of hepatobiliary and pancreatic surgery of 900th Hospital at the Joint Logistics Support Force of the Chinese People's Liberation Army between January 2013 and January 2018. 319 patients who underwent surgery for hepatocellular carcinoma were analysed ; and categorized into the two groups according to usage of argon plasma coagulation and the electrosurgical monopolar knife as secondary hemostatic surgical instruments. After 1:1 propensity score matching analysis, differences between two groups were assessed in terms of postoperative clinical outcomes. Multivariate logistic regression analysis was performed to identify independent factors associated with postoperative complications. After propensity score matching analysis, the group in which argon plasma coagulation was used for secondary hemostasis had a significantly lower postoperative complication rate compared to the group that used electrosurgical monopolar knife (p:0.033).A lower rate of complications graded according to Clavien-Dindo classification (grade III-V) was also seen in APC group (p:0.030). Moreover, the APC group had significantly less seen complications of bile leakage (p:0.015), ascites (p:0.011), and intra-abdominal infection (p:0.030). Multivariate analysis revealed the use of APC as an independent factor effective on postoperative complications (OR: 0.42, 95% CI: 0.21-0.84). The use of APC during curative resection of HCC decreased the incidence of postoperative complications in comparison with EK.

Hepatocellular carcinoma (HCC) is still a leading indication of Surgical resection of a portion of the liver. Laparoscopic and robotic liver resections are some of the techniques that are becoming increasingly common. Although RLR is more dextrous and precise, its benefits over LLR remain controversial because of the variation in the methodology of studies and patient selection. This meta-analysis compared perioperative outcomes between robotic and laparoscopic liver resection in HCC, focusing on operative time, hospital stay, morbidity, mortality, transfusion needs, and bile leak rates. The quality of evidence was assessed using the GRADE approach. A systematic search of PubMed, Scopus, and Cochrane identified 520 records. Five multicenter propensity score-matched cohort studies involving 3,616 patients (Robotic: 3,283; Laparoscopic: 333) met the inclusion criteria. Data on perioperative outcomes were pooled, and the Newcastle-Ottawa Scale (NOS) was used to evaluate the methodological quality of the studies. Compared with laparoscopic resection, robotic liver resection had a longer operative time (MD: -35.15min, 95% CI: -64.90 to - 5.39; p = 0.02; I² = 38%). However, there were no significant differences in blood transfusion rates (RR: 1.50, 95% CI: 0.41-5.47; p = 0.54), bile leaks (RR: 2.11, 95% CI: 0.59-7.52; p = 0.25), hospital stays (MD: -0.19 days, 95% CI: -2.42 to 2.05; p = 0.87; I² = 95%), or conversion to open surgery (RR: 1.22, 95% CI: 0.42-3.59; p = 0.71). RLR showed higher 30-day morbidity (RR: 1.59, 95% CI: 1.04-2.42; p = 0.03), while 90-day mortality did not differ significantly between the two approaches (RR: 4.33, 95% CI: 0.84-22.41; p = 0.08). RLR yields comparable results to LLR in HCC, with no differences in mortality or conversion rates but longer operative times and slightly higher short-term morbidity. Evidence quality was low to very low, emphasizing the need for well-designed randomized trials to inform surgical choices.

The Textbook Outcome (TBO) is a novel quality measure in pancreatic surgery, reflecting an ideal surgical outcome. This study aimed to identify the risk factors associated with achieving a TBO after pancreaticoduodenectomy. We retrospectively reviewed the records of 215 patients who underwent pancreaticoduodenectomy between 2016 and 2023. A TBO was defined as the absence of all six of the following parameters: 30-day mortality, readmission, postoperative pancreatic fistula, bile leakage, post-pancreatectomy hemorrhage, and severe complications (Clavien-Dindo grade ≥ III). Logistic regression was used to evaluate the impact of various factors, including nutritional status and body composition, on TBO achievement. A TBO was achieved in 123 (57.2%) patients. There were no cases of 30-day mortality reported. A multivariate analysis identified age ≥ 75 years, a soft pancreas, malnutrition as assessed by the GLIM criteria, and a high visceral fat area/skeletal muscle area ratio (VFA/SMA ratio) as significant risk factors for not achieving a TBO. Additionally, patients who achieved a TBO had a significantly better overall survival than those who did not achieve a TBO. This study underscores the importance of evaluating the nutritional status and body composition to improve surgical quality. Optimizing these factors preoperatively may support the achievement of a Textbook Outcome and improve the prognosis following pancreaticoduodenectomy.

Endoscopic retrograde cholangiopancreatography (ERCP) is a crucial diagnostic and therapeutic modality for managing bile leaks, particularly in the context of traumatic etiologies. Here, we aimed to contribute to this body of knowledge by providing a comprehensive analysis of ERCP outcomes in patients with confirmed bile leaks, including both traumatic and non-traumatic etiologies. This retrospective study investigated ERCP outcomes in patients with confirmed bile leaks from 2017 to 2023. Patients were categorized into non-traumatic (N = 124) and traumatic (N = 47) groups, collecting variables encompassing demographics, clinical parameters, and intervention details. The comparisons between groups utilized Chi-square for categorical variables. This study analyzed 188 bile duct leak cases, comparing 141 non-traumatic and 47 traumatic injuries. Logistic regression identified younger age (< 40 years; aOR:19.75, p < 0.001), male sex (aOR:6.45, p = 0.001), and Black race (aOR:3.41, p = 0.019) as significant predictors of traumatic injury. Hospital stay was significantly longer in traumatic cases (21.3 vs 12.4 days; p = 0.002), reflecting greater injury severity and complexity, including a higher need for interventional radiology (59.6% vs 33.3%; p = 0.001). Despite these differences, clinical outcomes, including stent success and complication rates, were comparable between groups. Our findings underscored a higher frequency of non-endoscopic involvement in traumatic injuries, indicating the complexity of these cases. Despite these differences, the study revealed that technical success, clinical success, mortality, and complications do not significantly differ between traumatic and non-traumatic groups, emphasizing the need for tailored management strategies outside of ERCP to address the distinct clinical characteristics of traumatic bile leaks.