Aude Vanlander

Patient-specific three-dimensional (3D) reconstruction converts cross-sectional imaging into individualised anatomical models of the liver, its vasculature and tumours and is increasingly used to plan hepatectomy. Its appeal is intuitive: it externalises the spatial reasoning that surgeons must otherwise perform mentally from two-dimensional images. Whether that appeal is matched by evidence varies greatly across the pathway from image to outcome. This critical review appraises the evidence chain—acquisition, segmentation, anatomical and quantitative representation, surgical planning, decision correctness, intraoperative translation and clinical benefit—against the reference standards appropriate to each step. The evidence is strongest where a physical referent exists: whole-liver and parenchymal segmentation are reproducible, and whole-liver and future-liver-remnant volumetry are among the best-validated outputs, albeit with characterised systematic and patient-level errors. It weakens progressively for tumour, small-vessel, arterial, biliary and territorial reconstruction and for computed vascular territories, which are inferred rather than directly observed. Reconstruction reliably changes operative plans, but whether those changes are correct is poorly established, and the operation performed is not an independent reference standard. Intraoperative registration remains approximately centimetric in several clinical series, and perioperative outcome and cost-effectiveness evidence is largely observational. The central message is that the maturity of 3D reconstruction is unevenly distributed: technical feasibility and volumetry are comparatively mature, whereas decision correctness, intraoperative validity and demonstrated patient benefit are not. Progress now depends less on more elaborate models than on reference standards, surgically meaningful validation metrics and prospective outcome evidence.

Background: Artificial intelligence (AI) is now applied across the pancreatic ductal adenocarcinoma (PDAC) pathway, yet the literature has grown faster than the evidence needed to act on it. The question is not whether an algorithm can predict an endpoint, but whether it yields information reliable, generalizable, and actionable enough to change a clinically meaningful decision. Methods: In this narrative, in a non-systematic review of PDAC-specific literature, we grade applications on an author-defined evidence-readiness framework (development, internal, external, prospective validation, clinical impact, and implementation) and on four dimensions—validation, comparator, actionability, and impact. Findings: Contemporary meta-analyses show high pooled accuracy for AI-based early detection and for distinguishing PDAC from mass-forming pancreatitis (sensitivity ~0.88–0.92, specificity ~0.90–0.93), but with extreme heterogeneity, low radiomics quality, scarce external validation, and—for electronic health-record risk models—positive predictive values often below 1% at population prevalence. Computed tomography (CT)-based detection and risk enrichment are among the more mature applications identified, yet none has been shown to improve stage distribution, resection rate, or survival. Treatment prediction is held to a strict standard, distinguishing prognostic association from a validated treatment-by-biomarker interaction. Conclusions: The rate-limiting steps are no longer algorithmic but translational—external and prospective validation, calibration, appropriate comparators, and workflow integration.

Laparoscopic cholecystectomy is among the most frequent abdominal operations worldwide, and its safety has improved across three decades. Major vascular injury nonetheless remains a rare but disproportionately lethal complication, capable of producing hepatic ischaemia, biliary stricture, liver failure and death. Bile duct injury has dominated the safety literature; vascular injury—isolated or, more often, combined with bile duct injury as a vasculobiliary injury—has been treated largely as bleeding to be controlled. This review argues that this framing is mistaken. Drawing on the observational literature, guidelines and emerging technologies, it advances one thesis: outcome depends far less on the vessel or repair technique than on where the injury sits on a predictable, systems-level cascade running from distorted anatomy, through cognitive fixation and unsafe dissection, to delayed recognition and non-expert management. We formalise this as the Vasculobiliary Injury Cascade, a three-phase model—predisposition, injury and trajectory—in which every transition is a defensible point of interruption and the determinants of survival lie disproportionately in the final phase. From it we derive a mechanism-specific account of prevention separating arterial misidentification from portal dissection injury, a three-layer defence integrating anatomical recognition, operative decision-making and technology, and a management approach of early recognition and timely referral rather than improvised repair.

Transcriptomic profiling reproducibly resolves pancreatic ductal adenocarcinoma (PDAC) into two prognostically divergent tumour-intrinsic programmes—classical/progenitor and basal-like/squamous—accompanied by a separable stromal axis; additional proposed classes are strongly influenced by low tumour cellularity and generalise poorly across datasets. Rather than cataloguing these programmes, this review synthesises evidence that they behave as plastic cell states and proposes an integrative developmental framework for interpreting that plasticity, rather than claiming its discovery. The framework combines a normal-pancreas developmental reference frame, the regulation of state by lineage transcription factors, epigenetic remodelling, oncogenic (KRAS) dosage, stromal instruction, and treatment pressure, and a testable notion of spatial disorganisation. Throughout, we separate robust prognostic evidence—basal-like assignment and low GATA6 expression are consistently associated with worse outcome—from predictive claims: predictive utility remains unproven because no completed prospective trial has assigned treatment according to classical–basal subtype and demonstrated improved clinical outcome from that strategy, and existing signals derive from retrospective or observational analyses. The proposition that the classical–basal spectrum reflects a spatially disordered redeployment of the normal duct’s luminal–basal hierarchy is presented as a hypothesis requiring validation in independent atlases rather than as established biology. We define the falsifiable experiments needed to test the framework and its clinical implications.

Background/Objectives: Cholecystectomy (CE) is among the most commonly performed surgical procedures worldwide. While it effectively treats gallstone disease, concerns have been raised about a potential long-term association with colorectal cancer (CRC), given overlapping risk factors and post-surgical physiological changes. Previous studies have reported inconsistent findings. This updated systematic review aimed to reassess the association between CE and CRC risk by incorporating the most recent evidence. Methods: In accordance with PRISMA 2020 guidelines, a systematic literature search was conducted in PubMed, Embase, Medline, Web of Science, and the Cochrane Library for studies published after May 2022. Eligible studies were observational cohort studies reporting relative risk estimates for CRC following CE. Data were extracted manually, and study quality was assessed using the NewcastleOttawa Scale (NOS). Only high-quality studies were included to update the systematic review. Publication bias was assessed using funnel plots and Egger’s test. Results: Out of 156 identified records, three new high-quality cohort studies met the inclusion criteria and were added to the 18 studies from the previous review, resulting in a total of 21 studies. The findings were heterogeneous: while no consistent association with overall CRC risk was observed, several studies reported an elevated risk of proximal (right-sided) colon cancer following CE. Egger’s test indicated no significant publication bias (p = 0.50). Conclusions: This updated systematic review suggests a potential association between CE and an increased risk of proximal colon cancer; however, the evidence remains inconclusive. Further prospective studies with robust confounder control and detailed tumor location-specific analyses are warranted to clarify causality and guide future screening strategies.

Hepatic arterial infusion (HAI) chemotherapy, first introduced in the 1980s, has gained recognition as an effective locoregional treatment for colorectal liver metastasis (CRLM). Initially used for unresectable liver metastases, HAI’s application has expanded to the adjuvant setting following hepatic resection, with early studies indicating improved hepatic disease-free survival. Recent research demonstrates that combining HAI with modern systemic therapies enhances conversion to resectability and prolongs both recurrence-free and overall survival, even in heavily pretreated patients with diverse RAS mutational statuses. Personalization through approaches like microsatellite instability status and dose modifications further optimize outcomes. However, the complexity of HAI requires expertise across multidisciplinary teams, limiting its widespread adoption to specialized centers. Ongoing clinical trials continue to investigate HAI’s role in CRLM management, highlighting its potential to become a cornerstone of liver-directed therapy. We explore how HAI chemotherapy, in combination with personalized medicine, can advance treatment strategies for metastatic colorectal cancer.

Purpose: Minimally invasive liver surgery (MILS) still appears to be adopted with significant variability. We aimed to investigate the diffusion, indications, and short-term outcomes of MILS compared to the open approach. Methods: A prospective registry of all liver resections performed for any indication and using any technique between January 1, 2017, and December 31, 2019, was established (BReLLS) and analyzed. Results: A total of 1342 consecutive liver resections were included, 684 (51%) MILS and 658 (49%) open procedures. MILS was not attempted due to technical complexity in the 46.2% of cases, followed by previous abdominal surgery (22.5%). Patients undergoing MILS had a higher proportion of benign indications and of hepatocellular carcinomas, patients affected by liver cirrhosis with portal hypertension and a lower proportion of major hepatectomies (all p < 0.001). After propensity-score matching, MILS showed better results in terms of surgery duration (p < 0.001), blood loss (p = 0.015), complication rate (p < 0.001), rate of Clavien-Dindo grade ≥ 3 complications (p = 0.012), comprehensive complication index (p < 0.001), length of stay (p < 0.001), readmissions (p = 0.016). Centers performing over 50 liver resections per year had a higher proportion of overall MILS cases (p < 0.001), a similar proportion of major resections (p = 0.362), but a higher prevalence of MILS major resections (p = 0.004), lower 90-day mortality rates (p < 0.001), lower overall complication rates (p < 0.001), and shorter hospital length of stay (p < 0.001). Conclusion: MILS was the preferred technique in half of the cases, particularly in patients with cirrhosis and portal hypertension, and benign lesions. It provided superior short-term outcomes compared to the open approach for both minor and major liver resections in selected patients.

Background With an increasing shortage of deceased donors for liver transplantation, living donor liver transplantation (LDLT) poses a valuable alternative. Therefore, it is important to investigate the risks healthy donors face during and after this procedure. We investigated complications and their impact on long-term health-related quality of life (HRQoL) and physical and mental functioning. Methods Thirty-three out of 51 Belgian liver donors who underwent a donor hepatectomy at the Ghent University Hospital from 1/1/2000 – 31/12/2015 consented to participate. Blood samples, a liver ultrasound, a clinical examination by a liver surgeon, and a socio-psychological interview supervised by a transplant psychologist were conducted. Additionally, participants completed a survey that examined the HRQoL (SF-36 and EQ-5D-3L), Depression, anxiety and stress (DASS), and donor experiences. Fischer’s exact, Mann-Whitney-U test, and Kruskal-Wallis tests were used, and statistical analysis was performed with SPSS 27.0. Results Donor complications were recorded in 24.8% without relation to long-term mental QoL and physical symptoms. Type of lobe donation had no significant effect on HRQoL, mood, anxiety and stress, and complications. Recipient complications and death, negative mood, anxiety, and stress were found to be related to a lower donor physical and mental HRQoL. Patients donating to pediatric recipients scored significantly better for mental and physical HRQoL. Conclusions Generally, donor experience is positive, with own complications having no lasting effect on QoL and mental health, however, complications in the recipient are more difficult to cope with and impact the mental HRQoL of the donor. LDLT in Belgium is ready to be standardized care for end-stage liver disease.