Arpad Ivanecz

Background: Bile duct injury (BDI) during (laparoscopic) cholecystectomy has an incidence of up to 1.5%. This retrospective study aimed to report the outcomes of surgical repair of BDI due to these procedures at a tertiary referral center. Methods: A retrospective review of patients’ records was conducted. The BDI’s clinical presentations, Strasberg classification, surgical repairs, and outcomes were reported. Results: From 2003 to 2024, 47 BDIs were identified. In total, 34.0% were recognized intraoperatively. The BDI types included Strasberg types B (2, 4.3%), C (5, 10.6%), D (11, 23.4%), E1 (4, 8.5%), E2 (12, 25.5%), E3 (5, 10.6%), E4 (3, 6.4%), and E5 (5, 10.6%). The T-tube group included 6 (12.8%) patients, the primary repair and T-tube group included 10 (21.3%) patients, and the Biliodigestive anastomosis group included 31 (65.9%) patients. The overall morbidity rate was 40.4%, the major morbidity rate was 21.3%, and the mortality rate was 4.3%. Grade A patency was achieved in 95.6% of patients. In the Biliodigestive anastomosis group, the actuarial 1-, 5- and 10-year grade A patency rates were 77.0%, 70.0%, and 70.0%, respectively. Conclusion: The rate of BDI remains stable. The outcomes of repairs in terms of complications and patency rates are comparable to those in other reports.

Laparoscopic distal pancreatectomy is a minimally invasive approach for the surgical treatment of neoplasms in the distal pancreas. This study aimed to compare this approach to the open procedure. A retrospective analysis of a prospectively maintained database of 400 pancreatectomies was performed. The laparoscopic distal pancreatectomy group (LDP) was compared to the open distal pancreatectomy group (ODP). A propensity score matching analysis (PSM) was performed. From 2016 to 2023, 108 distal pancreatectomies were carried out, 19 (17.6%) laparoscopically and 89 (82.4%) openly. The conversion rate was 13.6%. The severe morbidity rates were 28.1% in the ODP group, 47.4% in the LDP group, and 15.8% in the ODP-PSM group. The difference between the latter two was statistically significant (p = 0.034) due to the high rate of Clavien–Dindo grade 3a complications (42.1% versus 10.5%, p = 0.042) in the LDP group. The 90-day mortality rates were 3.3% in the ODP group and 5.3% in the other two groups. The LDP group had a shorter duration of intravenous narcotic analgesia (5 versus 7 days, p = 0.041). There was no difference in the R0 resection or postoperative pancreatic fistula rates. Our attention should be drawn to preventing postoperative complications because the oncological outcomes are already comparable with those of the open procedure, and postoperative pain management is promising.

Introduction Obesity is a major public health problem and a well-known cause of multiple comorbidities. With the increasing application of minimally invasive surgery for benign and malignant liver lesions, the results of laparoscopic liver resection (LLR) in obese patients are of great...

Background: Two-stage hepatectomy (TSH) has been proposed for patients with bilateral liver tumours who have a high risk of posthepatectomy liver failure after one-stage hepatectomy (OSH). This study aimed to determine the outcomes of TSH for extensive bilateral colorectal liver metastases. Patients and methods: A retrospective review of a prospectively maintained database of liver resections for colorectal liver metastases was conducted. The TSH group was compared to the OSH group in terms of perioperative outcomes and survival. Case-control matching was performed. Results: A total of 632 consecutive liver resections for colorectal liver metastases were performed between 2000 and 2020. The study group (TSH group) consisted of 15 patients who completed TSH. The control group included 151 patients who underwent OSH. The case-control matching-OSH group consisted of 14 patients. The major morbidity and 90-day mortality rates were 40% and 13.3% in the TSH group, 20.5% and 4.6% in the OSH group and 28.6% and 7.1% in the case-control matching-OSH group, respectively. The recurrence-free survival, median overall survival, and 3- and 5-year survival rates were 5 months, 21 months, 33% and 13% in the TSH group; 11 months, 35 months, 49% and 27% in the OSH group; and 8 months, 23 months, 36% and 21%, respectively, in the case-control matching-OSH group, respectively. Conclusions: TSH used to be a favourable therapeutic choice in a select population of patients. Now, OSH should be preferred whenever feasible because it has lower morbidity and equivalent oncological outcomes to those of completed TSH.

Background: The aim of this multicentric study was to investigate the impact of tumor location and size on the difficulty of Laparoscopic‐Left Hepatectomy (L‐LH).Methods: Patients who underwent L‐LH performed across 46 centers from 2004 to 2020 were analyzed. Of 1236 L‐LH, 770 patients met the study criteria. Baseline clinical and surgical characteristics with a potential impact on LLR were included in a multi‐label conditional interference tree. Tumor size cut‐off was algorithmically determined.Results: Patients were stratified into 3 groups based on tumor location and dimension: 457 in antero‐lateral location (Group 1), 144 in postero‐superior segment (4a) with tumor size ≤40 mm (Group 2), and 169 in postero‐superior segment (4a) with tumor size >40 mm (Group 3). Patients in the Group 3 had higher conversion rate (7.0% vs. 7.6% vs. 13.0%, p‐value .048), longer operating time (median, 240 min vs. 285 min vs. 286 min, p‐value <.001), greater blood loss (median, 150 mL vs. 200 mL vs. 250 mL, p‐value <.001) and higher intraoperative blood transfusion rate (5.7% vs. 5.6% vs. 11.3%, p‐value .039). Pringle's maneuver was also utilized more frequently in Group 3 (66.7%), compared to Group 1 (53.2%) and Group 2 (51.8%) (p = .006). There were no significant differences in postoperative stay, major morbidity, and mortality between the three groups.Conclusion: L‐LH for tumors that are >40 mm in diameter and located in PS Segment 4a are associated with the highest degree of technical difficulty. However, post‐operative outcomes were not different from L‐LH of smaller tumors located in PS segments, or tumors located in the antero‐lateral segments.

Background: Tumor size (TS) represents a critical parameter in the risk assessment of laparoscopic liver resections (LLR). Moreover, TS has been rarely related to the extent of liver resection. The aim of this study was to study the relationship between tumor size and difficulty of laparoscopic left lateral sectionectomy (L‐LLS).Methods: The impact of TS cutoffs was investigated by stratifying tumor size at each 10 mm‐interval. The optimal cutoffs were chosen taking into consideration the number of endpoints which show a statistically significant split around the cut‐points of interest and the magnitude of relative risk after correction for multiple risk factors.Results: A total of 1910 L‐LLS were included. Overall, open conversion and intraoperative blood transfusion were 3.1 and 3.3%, respectively. The major morbidity rate was 2.7% and 90‐days mortality 0.6%. Three optimal TS cutoffs were identified: 40‐, 70‐, and 100‐mm. All the selected cutoffs showed a significant discriminative power for the prediction of open conversion, operative time, blood transfusion and need of Pringle maneuver. Moreover, 70‐ and 100‐mm cutoffs were both discriminative for estimated blood loss and major complications. A stepwise increase in rates of open conversion rate (Z = 3.90, P < .001), operative time (Z = 3.84, P < .001), blood loss (Z = 6.50, P < .001), intraoperative blood transfusion rate (Z = 5.15, P < .001), Pringle maneuver use (Z = 6.48, P < .001), major morbidity(Z = 2.17, P = .030) and 30‐days readmission (Z = 1.99, P = .047) was registered as the size increased.Conclusion: L‐LLS for tumors of increasing size was associated with poorer intraoperative and early postoperative outcomes suggesting increasing difficulty of the procedure. We determined three optimal TS cutoffs (40‐, 70‐ and 100‐mm) to accurately stratify surgical difficulty after L‐LLS.

Background: Presently, according to different difficulty scoring systems, there is no difference in complexity estimation of laparoscopic liver resection (LLR) of segments 7 and 8. However, there is no published data supporting this assumption. To date, no studies have compared the outcomes of laparoscopic parenchyma‐sparing resection of the liver segments 7 and 8.Methods: A post hoc analysis of patients undergoing LLR of segments 7 and 8 in 46 centers between 2004 and 2020 was performed. 1:1 Propensity score matching (PSM) was used to compare isolated LLR of segments 7 and 8. Subset analyses were also performed to compare atypical resections and segmentectomies of 7 and 8.Results: A total of 2411 patients were identified, and 1691 patients met the inclusion criteria. Comparison after PSM between the entire cohort of segment 7 and segment 8 resections revealed inferior results for segment 7 resection in terms of increased blood loss, blood transfusions, and conversions to open surgery. Subset analyses of only atypical resections similarly demonstrated poorer outcomes for segment 7 in terms of increased blood loss, operation time, blood transfusions, and conversions to open surgery. Conversely, a subgroup analysis of segmentectomies after PSM found better outcomes for segment 7 in terms of a shorter operation time and hospital stay.Conclusion: Differences in the outcomes of segments 7 and 8 resections suggest a greater difficulty of laparoscopic atypical resection of segment 7 compared to segment 8, and greater difficulty of segmentectomy 8 compared to segmentectomy 7.

Background: Robotic liver resections (RLR) may have the ability to address some of the drawbacks of laparoscopic liver resections (LLR) but few studies have done a head‐to‐head comparison of the outcomes after anterolateral segment resections by the two techniques.Methods: A retrospective study was conducted of 3202 patients who underwent minimally invasive LR of the anterolateral liver segments at 26 international centres from 2005 to 2020. Two thousand six hundred and six cases met study criteria of which there were 358 RLR and 1868 LLR cases. Perioperative outcomes were compared between the two groups using a 1:3 Propensity Score Matched (PSM) and 1:1 Coarsened Exact Matched (CEM) analysis.Results: Patients matched after 1:3 PSM (261 RLR vs 783 LLR) and 1:1 CEM (296 RLR vs 296 LLR) revealed no significant differences in length of stay, readmission rates, morbidity, mortality, and involvement of or close oncological margins. RLR surgeries were associated with significantly less blood loss (50 mL vs 100 ml, P < .001) and lower rates of open conversion on both PSM (1.5% vs 6.8%, P = .003) and CEM (1.4% vs 6.4%, P = .004) compared to LLR. Though PSM analysis showed RLR to have a longer operating time than LLR (170 minutes vs 160 minutes, P = .036), this difference proved to be insignificant on CEM (167 minutes vs 163 minutes, P = .575).Conclusion: This multicentre international combined PSM and CEM study showed that both RLR and LLR have equivalent perioperative outcomes when performed in selected patients at high‐volume centres. The robotic approach was associated with significantly lower blood loss and allowed more surgeries to be completed in a minimally invasive fashion.

Purpose: Malrotation with midgut volvulus is a rare congenital anomaly that generally presents acutely in the neonatal period, with bilious vomiting, and requires surgical intervention. It is rarely observed beyond the first year of life, when the diagnosis can be difficult because of intermittent symptoms and vague clinical findings, which can subsequently delay appropriate treatment. Chronic volvulus associated with malrotation has the potential to turn into acute vascular congestion and arterial insufficiency secondary to torsion of the superior mesenteric vessels. Early diagnosis and surgical treatment are essential to prevent progression to transmural bowel infarction. Case report: We present the case of a 3-year-old boy with a 1-year history of recurrent abdominal pain and intermittent vomiting, which was evaluated many times at other institutions without a definitive diagnosis. Finally, the boy was referred as an emergency, with signs of an acute abdomen and septic shock. Upon urgent laparotomy, midgut volvulus caused by malrotation with extensive intestinal necrosis was found, which necessitated an extreme resection of the small bowel. The postoperative course was uneventful, and presently, 1 year after the operation, the boy is on total parenteral nutrition, thrives normally, eats regular food, and has no diarrhea or signs of liver failure. Although there is some impairment in his quality of life, he can practice almost completely normal daily activities for a child of his age. Conclusion: In this article, we discuss the diagnostic pitfalls that can occur when symptoms of midgut malrotation develop beyond the neonatal period, the difficulties of management in an emergency setting, and therapeutic options for the patient after massive small bowel resection.