ABDOMINALE CHIRURGIE

CENTRUM ABDOMINALE CHIRURGIE

ARTIKELS

ABSTRACT 1

Impact of resection margins for colorectal liver metastases in laparoscopic and open liver resection: a propensity score analysis.

Martínez-Cecilia D, Wicherts D, Cipriani F, D'Hondt M, et al .

Surgical endoscopy, 2021, 35(2), 809-818

ABSTRACT There is no clear consensus over the optimal width of resection margin for colorectal liver metastases (CRLM), with evolving definitions alongside the advances on the management of the disease. In addition, data on the impact of resection margin after laparoscopic liver resection are still scarce. Prospectively maintained databases of patients undergoing open or laparoscopic CRLM resection in 7 European tertiary hepatobiliary referral centres were reviewed. After propensity score matching (PSM), the influence of 1 mm and wider margins on OS and DFS were evaluated in open and laparoscopic cohorts.

After PSM, 648 patients were comparable in each group. The incidence of positive margins (< 1 mm) was similar in open and laparoscopic groups (17% vs 13%, p = 0,142). Margins < 1 mm were associated with shorter RFS in open (12 vs 26 months, p = 0.042) and in laparoscopic group (13 vs 23, p = 0,002). Margins < 1 mm were associated with shorter OS in open (36 vs 57 months, p = 0.027), but not in laparoscopic group (49 vs 60, p = 0,177). Subgroups with margins ≥ 1 mm (1-4 mm, 5-9 mm, ≥ 10 mm) presented similar RFS in open (p = 0,251) or laparoscopic cohorts (p = 0.117), as well as similar OS in open (p = 0.295) or laparoscopic cohorts (p = 0.908). In the presence of liver recurrence, repeat liver resection was performed in 70 (30%) patients in the open group and 88 (48%) in the laparoscopic group (p < 0.001).

Our study suggests that a positive resection margin (less than 1 mm) width does not impact OS after laparoscopic resection of CRLMs as it does in open liver resection. However, a positive margin continues to affect RFS in open and laparoscopic resection. Wider margins than 1 mm do not seem to improve oncological results in open or laparoscopic surgery. ABSTRACT 2

Updated alternative fistula risk score (ua-frs) to include minimally invasive pancreatoduodenectomy: paneuropean validation.

Mungroop T, Klompmaker S, Wellner U, D'Hondt M, et al.

Annals of surgery, 2021, 273(2), 334-340

ABSTRACT MIPD may be associated with an increased risk of postoperative pancreatic fistula (POPF). The a-FRS could allow for risk-adjusted comparisons in research and improve preventive strategies for high-risk patients. The a-FRS, however, has not yet been validated specifically for laparoscopic, robot-assisted, and hybrid MIPD. The aim of the study was to validate and optimize the alternative Fistula Risk Score (a-FRS) for patients undergoing minimally invasive pancreatoduodenectomy (MIPD) in a large pan-European cohort.

A validation study was performed in a pan-European cohort of 952 consecutive patients undergoing MIPD (543 laparoscopic, 258 robot-assisted, 151 hybrid) in 26 centers from 7 countries between 2007 and 2017. The primary outcome was POPF (International Study Group on Pancreatic Surgery grade B/C). Model performance was assessed using the area under the receiver operating curve (AUC; discrimination) and calibration plots. Validation included univariable screening for clinical variables that could improve performance. Overall, 202 of 952 patients (21%) developed POPF after MIPD. Before adjustment, the original a-FRS performed moderately (AUC 0.68) and calibration was inadequate with systematic underestimation of the POPF risk. Single-row pancreatojejunostomy (odds ratio 4.6, 95 confidence interval [CI] 2.8-7.6) and male sex (odds ratio 1.9, 95 CI 1.4-2.7) were identified as important risk factors for POPF in MIPD. The updated a-FRS, consisting of body mass index, pancreatic texture, duct size, and male sex, showed good discrimination (AUC 0.75, 95 CI 0.71-0.79) and adequate calibration. Performance was adequate for laparoscopic, robot-assisted, and hybrid MIPD and open pancreatoduodenectomy.

The updated a-FRS (www.pancreascalculator.com) now includes male sex as a risk factor and is validated for both MIPD and open pancreatoduodenectomy. The increased risk of POPF in laparoscopic MIPD was associated with single-row pancreatojejunostomy, which should therefore be discouraged.

ABSTRACT 3

Hybrid minimally invasive esophagectomy to the rescue: a valid alternative for phased dissemination of tmie?

Nuytens F, Voron T, Piessen G

Journal of Clinical Oncology, 2021, 39(1), 91-92

ABSTRACT Er is geen abstract beschikbaar.

ABSTRACT 4

Five-year survival outcomes of hybrid minimally invasive esophagectomy in esophageal cancer: results of the miro randomized clinical trial.

Nuytens F, Dabakuyo-Yonli TS, Meunier B, et al. JAMA Surgery, 2021, 156(4), 323-332

ABSTRACT Available data comparing the long-term results of hybrid minimally invasive esophagectomy (HMIE) with that of open esophagectomy are conflicting, with similar or even better results reported for the minimally invasive esophagectomy group. To evaluate the long-term, 5-year outcomes of HMIE vs open esophagectomy, including overall survival (OS), disease-free survival (DFS), and pattern of disease recurrence, and the potential risk factors associated with these outcomes.

This randomized clinical trial is a post hoc follow-up study that analyzes the results of the open-label Multicentre Randomized Controlled Phase III Trial, which enrolled patients from 13 different centers in France and was conducted from October 26, 2009, to April 4, 2012. Eligible patients were 18 to 75 years of age and were diagnosed with resectable cancer of the middle or lower third of the esophagus. After exclusions, patients were randomized to either the HMIE group or the open esophagectomy group. Data analysis was performed on an intention-to-treat basis from November 19, 2019, to December 4, 2020. Interventions: Hybrid minimally invasive esophagectomy (laparoscopic gastric mobilization with open right thoracotomy) was compared with open esophagectomy. Main outcomes and measures: The primary end points of this follow-up study were 5-year OS and DFS. The secondary end points were the site of disease recurrence and potential risk factors associated with DFS and OS. A total of 207 patients were randomized, of whom 175 were men (85%), and the median (range) age was 61 (23-78) years. The median follow-up duration was 58.2 (95% CI, 56.5-63.8) months. The 5-year OS was 59% (95% CI, 48%-68%) in the HMIE group and 47% (95% CI, 37%-57%) in the open esophagectomy group (hazard ratio [HR], 0.71; 95% CI, 0.48-1.06). The 5-year DFS was 52% (95% CI, 42%-61%) in the HMIE group vs 44% (95% CI, 34%-53%) in the open esophagectomy group (HR, 0.81; 95% CI, 0.55-1.17). No statistically significant difference in recurrence rate or location was found between groups. In a multivariable analysis, major intraoperative and postoperative complications (HR, 2.21; 95% CI, 1.41-3.45; P < .001) and major pulmonary complications (HR, 1.94; 95% CI, 1.21-3.10; P = .005) were identified as risk factors associated with decreased OS. Similarly, multivariable analysis of DFS identified overall intraoperative and postoperative complications (HR, 1.93; 95% CI, 1.28-2.90; P = .002) and major pulmonary complications (HR, 1.85; 95% CI, 1.192.86; P = .006) as risk factors.

This study found no difference in long-term survival between the HMIE and open esophagectomy groups. Major postoperative overall complications and pulmonary complications appeared to be independent risk factors in decreased OS and DFS, providing additional evidence that HMIE may be associated with improved oncological results compared with open esophagectomy primarily because of a reduction in postoperative complications.

ABSTRACT 5

International multicenter propensity score matched study on laparoscopic versus open left lateral sectionectomy.

van der Poel M, Fichtinger R, Gorgec B, D'Hondt M, et al. Hepato-pancreato-biliary (HPB) surgery - Oxford Medicine, 2021, 23(5), 707-714

ABSTRACT Despite a lack of high-level evidence, current guidelines recommend laparoscopic left lateral sectionectomy (LLLS) as the routine approach over openLLS (OLLS). Randomized studies and propensity score matched studies on LLLS vs OLLS for all indications, including malignancy, are lacking.

This international multicenter propensity score matched retrospective cohort study included consecutive patients undergoing LLLS or OLLS in six centers from three European countries (January 2000-December 2016). Propensity scores were calculated based on nine preoperative variables and LLLS and OLLS were matched in a 1:1 ratio. Short-term operative outcomes were compared using paired tests.

A total of 560 patients were included. Out of 200 LLLS, 139 could be matched to 139 OLLS. After matching, baseline characteristics were well balanced. LLLS was associated with shorter operative time (144 (110-200) vs 199 (138283) minutes, P < 0.001), less blood loss (100 (50-300) vs 350 (100-750) mL, P = 0.005) and a 3-day shorter postoperative hospital stay (4 (3-7) vs 7 (5-9) days, P < 0.001).

This international multicenter propensity score matched study confirms the superiority of LLLS over OLLS based on shorter postoperative hospital stay, operative time and less blood loss thus validating current guideline advice.

ABSTRACT 6

Risk of conversion to open surgery during robotic and laparoscopic pancreatoduodenectomy and effect on outcomes: international propensity score-matched comparison study.

Lof S, Vissers F, Klompmaker S, Berti S, D'Hondt M British Journal of Surgery, 2021, 108(1), 80-87

ABSTRACT Minimally invasive pancreatoduodenectomy (MIPD) is increasingly being performed because of perceived patient benefits. Whether conversion of MIPD to open pancreatoduodenectomy worsens outcome, and which risk factors are associated with conversion, is unclear.

This was a post hoc analysis of a European multicentre retrospective cohort study of patients undergoing MIPD (2012-2017) in ten medium-volume (10-19 MIPDs annually) and four high-volume (at least 20 MIPDs annually) centres. Propensity score matching (1 : 1) was used to compare outcomes of converted and non-converted MIPD procedures. Multivariable logistic regression analysis was performed to identify risk factors for conversion, with results presented as odds ratios (ORs) with 95 per cent confidence intervals (c.i).

Overall, 65 of 709 MIPDs were converted (9.2 per cent) and the overall 30-day mortality rate was 3.8 per cent. Risk factors for conversion were tumour size larger than 40 mm (OR 2.7, 95 per cent c.i.1.0 to 6.8; P = 0.041), pancreatobiliary tumours (OR 2.2, 1.0 to 4.8; P = 0.039), age at least 75 years (OR 2.0, 1.0 to 4.1; P = 0.043), and laparoscopic pancreatoduodenectomy (OR 5.2, 2.5 to 10.7; P < 0.001). Medium-volume centres had a higher risk of conversion than high-volume centres (15.2 versus 4.1 per cent, P < 0.001; OR 4.1, 2.3 to 7.4, P < 0.001). After propensity score matching (56 converted MIPDs and 56 completed MIPDs) including risk factors, rates of complications with a Clavien-Dindo grade of III or higher (32 versus 34 per cent; P = 0.841) and 30-day mortality (12 versus 6 per cent; P = 0.274) did not differ between converted and non-converted MIPDs.

Risk factors for conversion during MIPD include age, large tumour size, tumour location, laparoscopic approach, and surgery in medium-volume centres. Although conversion during MIPD itself was not associated with worse outcomes, the outcome in these patients was poor in general which should be taken into account during patient selection for MIPD.

ABSTRACT 7

Robotic versus laparoscopic distal pancreatectomy: multicentre analysis.

Lof S, van der Heijde N, Abuawwad M, D'Hondt M, et al. British Journal of Surgery,2021, 108(2), 188-195

ABSTRACT The role of minimally invasive distal pancreatectomy is still unclear, and whether robotic distal pancreatectomy (RDP) offers benefits over laparoscopic distal pancreatectomy (LDP) is unknown because large multicentre studies are lacking. This study compared perioperative outcomes between RDP and LDP.

A multicentre international propensity score-matched study includedpatients who underwent RDP or LDP for any indication in 21 European centres from six countries that performed at least 15 distal pancreatectomies annually (January 2011 to June 2019). Propensity score matching was based on preoperative characteristics in a 1 : 1 ratio. The primary outcome was the major morbidity rate (ClavienDindo grade IIIa or above). A total of 1551 patients (407 RDP and 1144 LDP) were included in thestudy. Some 402 patients who had RDP were

matched with 402 who underwent LDP. After matching, there was no difference between RDP and LDP groups in rates of major morbidity (14.2 versus 16.5 per cent respectively; P = 0.378), postoperative pancreatic fistula grade B/C (24.6 versus 26.5 per cent; P = 0.543) or 90-day mortality (0.5 versus 1.3 per cent; P = 0.268). RDP was associated with a longer duration of surgery than LDP (median 285 (i.q.r. 225-350) versus 240 (195-300) min respectively; P < 0.001), lower conversion rate (6.7 versus 15.2 per cent; P < 0.001), higher spleen preservation rate (81.4 versus 62.9 per cent; P = 0.001), longer hospital stay (median 8.5 (i.q.r. 7-12) versus 7 (6-10) days; P < 0.001) and lower readmission rate (11.0 versus 18.2 per cent; P = 0.004).

The major morbidity rate was comparable between RDP and LDP. RDP was associated with improved rates of conversion, spleen preservation and readmission, to the detriment of longer duration of surgery and hospital stay.

ABSTRACT 8

An unexpected cause of persistent bacteraemia and portomesenteric venous gas.

Loobuyck A, Vermeersch G, D'Hondt M Acta Gastro-Enterologica Belgica, 84(2), 2021, 375-377

ABSTRACT We report the case of a 59-year old man with portomesenteric venous gas (PMVG) due to inferior mesenteric vein fistulization caused by sigmoid diverticulitis with an unusual evolution.

The patient initially presented with classic symptoms of lower abdominal pain and fever. Diagnosis of uncomplicated sigmoid diverticulitis was confirmed on computed tomography (CT) for which intravenous antibiotics were initiated. Hemocultures were positive for omnisensitive Escherichia Coli, but despite adequate intravenous antibiotic therapy, episodes of bacteraemia persisted and hemocultures remained positive. Repeat CT scan demonstrated regression of inflammation without signs of abcedation or perforation consistent with clinical findings. Endocarditis was excluded with a normal transoesophageal echocardiography.

Finally, positron emission tomography-computed tomography (PET-CT) suspected a colovenous fistula and the presence of PMVG. The patient was successfully treated with laparoscopic sigmoidectomy. This case report summarises the diagnostic pathway and aims for higher awareness of non-ischemic PMVG causes.

ABSTRACT 9

An unexpected liver lesion?

De Somer T, D'Hondt M, Carels K Acta Gastro-Enterologica Belgica, 2021, 84(2), 385-386

ABSTRACT Er is geen abstract beschikbaar.

ABSTRACT 10

Radiofrequency ablation and chemotherapy versus chemotherapy alone for locally advanced pancreatic cancer (PELICAN): study protocol for a randomized controlled trial.

Walma MS, Rombouts SJ, Brada LJH, D'Hondt M, et al. Trials, 2021, 22(1), 313

ABSTRACT Approximately 80% of patients with locally advanced pancreatic cancer (LAPC) are treated with chemotherapy, of whom approximately 10% undergo a resection. Cohort studies investigating local tumor ablation with radiofrequency ablation (RFA) have reported a promising overall survival of 26-34 months when given in a multimodal setting. However, randomized controlled trials (RCTs) investigating the effect of RFA in combination with chemotherapy in patients with LAPC are lacking.

The "Pancreatic Locally Advanced Unresectable Cancer Ablation" (PELICAN) trial is an international multicenter superiority RCT, initiated by the Dutch Pancreatic Cancer Group (DPCG). All patients with LAPC according to DPCG criteria, who start with FOLFIRINOX or (nab-paclitaxel/) gemcitabine, are screened for eligibility. Restaging is performed after completion of four cycles of FOLFIRINOX or two cycles of (nab-paclitaxel/)gemcitabine (i.e., 2 months oftreatment), and the results are assessed within a nationwide online expert panel. Eligible patients with RECIST stable disease or objective response, in whom resection is not feasible, are randomized to RFA followed by chemotherapy or chemotherapy alone. In total, 228 patients will be included in 16 centers in The Netherlands and four other European centers.

The primary endpoint is overall survival. Secondary

endpoints include progression-free survival, RECIST response, CA 19.9 and CEA response, toxicity, quality of life, pain, costs, and immunomodulatory effects of RFA.

The PELICAN RCT aims to assess whether the combination of chemotherapy and RFA improves the overall survival when compared to chemotherapy alone, in patients with LAPC with no progression of disease following 2 months of systemic treatment. 184min, p = 0.033) and less blood loss (100 vs 150ml, p < 0.001) as compared to Warshaw MIDP. Unplanned splenectomy was associated with a higher conversion rate (20.7% vs 5.0%, p < 0.001). Kimura and Warshaw spleen-preserving MIDP provide equivalent short-term outcomes with low rates of secondary splenectomy and postoperative morbidity.

Further analyses of long-term outcomes are needed.

ABSTRACT 11

Short-term outcomes after spleen-preserving minimally invasive distal pancreatectomy with or without preservation of splenic vessels: a pan-european retrospective study in high-volume centers.

Korrel M, Lof S, Sarireh BA, D'Hondt M, et al. Annals of Surgery, 2021, doi: 10.1097/ SLA.0000000000004963

ABSTRACT Spleen preservation during distal pancreatectomy can be achieved by either preservation (Kimura) or resection (Warshaw) of the splenic vessels. Multicenter studies reporting outcomes of Kimura and Warshaw spleen-preserving MIDP are scarce. To compare short-term clinical outcomes after Kimura and Warshaw minimally invasive distal pancreatectomy (MIDP).

Multicenter retrospective study including consecutive MIDP procedures intended to be spleen-preserving from 29 high-volume centers (≥15 distal pancreatectomies annually) in eight European countries. Primary outcomes were secondary splenectomy for ischemia and major (Clavien-Dindo grade ≥III) complications. Sensitivity analysis assessed the impact of excluding ('rescue') Warshaw procedures which were performed in centers that typically (>75%) performed Kimura MIDP.

Overall, 1095 patients after MIDP were included with successful splenic preservation in 878 patients (80%), including 634 Kimura and 244 Warshaw procedures. Rates of clinically relevant splenic ischemia (0.6% vs. 1.6%, p = 0.127) and major complications (11.5% vs 14.4%, p = 0.308) did not differ significantly between Kimura and Warshaw MIDP, respectively. Mortality rates were higher after Warshaw MIDP (0.0% vs. 1.2%, p = 0.023), and decreased in the sensitivity analysis (0.0% vs 0.6%, p = 0.052). Kimura MIDP was associated with longer operative time (202 vs ABSTRACT 12

Laparoscopic liver resection for colorectal liver metastases - short- and long-term outcomes: A systematic review.

Taillieu E,De Meyere C, Nuytens F, Verslype C,

D'Hondt M, et al. World Journal of Gastrointestinal Oncology, 2021, 13(7), 732-757

ABSTRACT For well-selected patients and procedures, laparoscopic liver resection (LLR) has become the gold standard for the treatment of colorectal liver metastases (CRLM) when performed in specialized centers. However, little is currently known concerning patient-related and peri-operative factors that could play a role in survival outcomes associated with LLR for CRLM.AIM: To provide an extensive summary of reported outcomes and prognostic factors associated with LLR for CRLM.

A systematic search was performed in PubMed, EMBASE, Web of Science and the Cochrane Library using the keywords "colorectal liver metastases", "laparoscopy", "liver resection", "prognostic factors", "outcomes" and "survival". Only publications written in English and published until December 2019 were included. Furthermore, abstracts of which no accompanying full text was published, reviews, case reports, letters, protocols, comments, surveys and animal studies were excluded. All search results were saved to Endnote Online and imported in Rayyan for systematic selection. Data of interest were extracted from the included publications and tabulated for qualitative analysis.

Out of 1064 articles retrieved by means of a systematic and grey literature search, 77 were included for qualitative analysis. Seventy-two research papers provided data concerning outcomes of LLR for CRLM. Fourteen papers were eligible for extraction of data concerning prognostic factors affecting survival outcomes. Qualitative analysis

of the collected data showed that LLR for CRLM is safe, feasible and provides oncological efficiency. Multiple research groups have reported on the short-term advantages of LLR compared to open procedures.

The obtained results accounted for minor LLR, aswell as major LLR, simultaneous laparoscopic colorectal and liver resection, LLR of posterosuperior segments, two-stage hepatectomy and repeat LLR for CRLM. Few research groups so far have studied prognostic factors affecting long-term outcomes of LLR for CRLM.

In experienced hands, LLR for CRLM provides good short- and long-term outcomes, independent of the complexity of the procedure.

ABSTRACT 13

Assessment of textbook outcome in laparoscopic and open liver surgery.

Görgec B, Benedetti, Cacciaguerra A, D'Hondt M, et al. JAMA surgery, 2021 , 156(8), doi: 10.1001/jamasurg.2021.2064

ABSTRACT Textbook outcome (TO) is a composite measure that captures the mostdesirable surgical outcomes as a single indicator, yet to date TO has not been defined and assessed in the field of laparoscopic liver resection (LLR) and open liver resection (OLR).

To obtain international agreement on the definition of TO in liver surgery (TOLS) and to assess the incidence of TO in LLR and OLR in a largeinternational multicenter database using a propensity-score matched analysis. DESIGN, SETTING, AND PARTICIPANTS: Patients undergoing LLR or OLR for all liver diseases between January 2011 and October 2019 were analyzed using a large international multicenter liver surgical database. An international survey was conducted among all members of the European-African HepatoPancreato-Biliary Association (E-AHPBA) and International Hepato-Pancreato-Biliary Association (IHPBA) to reach agreement on the definition of TOLS. The rate of TOLS was assessed for LLR and OLR before and after propensity-score matching. Factors associated with achieving TOLS were investigated.

Textbook outcome, with TOLS defined as the absence of intraoperative incidents of grade 2 or higher, postoperative bile leak grade B or C, severe postoperative complications, readmission within 30 days after discharge, in-hospital mortality, and the presence of R0 resection margin. A total of 8188 patients (4559 LLR; median age, 65 years [interquartile range, 55-73 years]; 2529 were male [55.8%] and 3629 OLR; median age, 64 years [interquartile range, 56-71 years]; 2204 were male [60.7%]) were included in the analysis of whom 69.1% achieved TOLS; 74.8% for LLR and 61.9% for OLR (P < .001). On multivariable analysis, American Society of Anesthesiologists grade III, previous abdominal surgery, histological diagnosis of colorectal liver metastases (odds ratio [OR], 0.656 [95% CI, 0.457-0.940]; P = .02), cholangiocarcinoma, non-CRLM, a tumor size of 30 mm or more, minor resection of posterior/superior segments (OR, 0.716 [95% CI, 0.577-0.887]; P = .002), anatomically major resection (OR, 0.579 [95% CI, 0.418-0.803]; P = .001), and nonanatomical resection (OR, 0.612 [95% CI, 0.476-0.788]; P < .001) were associated with a worse TOLS rate after LLR. For OLR, only histological diagnosis of cholangiocarcinoma (OR, 0.360 [95% CI, 0.214-0.607]; P < .001) and a tumor size of 30 mm or more (30-50 mm = OR, 0.718 [95% CI, 0.565-0.911]; P = .01; 50.1-100 mm = OR, 0.729 [95% CI, 0.554-0.960]; P = .02; >10 cm = OR, 0.550 [95% CI, 0.3660.826]; P = .004) were associated with a worse TOLS rate.

In this multicenter study, TOLS was found to be a useful tool for assessing patient-level hospital performance and may have utility in optimizing patient outcomes after LLR and OLR.

ABSTRACT 14

Laparoscopic versus open right posterior sectionectomy: an international, multicenter, propensity score-matched evaluation.

van der Heijde N, Ratti F, Aldrighetti L, D'Hondt M, et al. Surgical Endoscopy, 2021, 5(11), 6139-6149

ABSTRACT Although laparoscopic liver resection has become the standard for minor resections, evidence is lacking for more complex resections such as the right posterior sectionectomy (RPS). We aimed to compare surgical outcomes between laparoscopic (LRPS) and open right posterior sectionectomy (ORPS). An international multicenter retrospective study comparing patients undergoing LRPS or ORPS (January 2007-December 2018) was performed. Patients were matched based on propensity scores in a 1:1 ratio. Primary endpoint was major complication rate defined as

Accordion ≥ 3 grade. Secondary endpoints included blood loss, length of hospital stay (LOS) and resection status. A sensitivity analysis was done excluding the first 10 LRPS patients of each center to correct for the learning curve. Additionally, possible risk factors were explored for operative time, blood loss and LOS. Overall, 399 patients were included from 9 centers from 6 European countries of which 150 LRPS could be matched to 150 ORPS. LRPS was associated with a shorter operative time [235 (195-285) vs. 247 min (195-315) p = 0.004], less blood loss [260 (188-400) vs. 400 mL (280-550) p = 0.009] and a shorter LOS [5 (4-7) vs. 8 days (6-10), p = 0.002]. Major complication rate [n = 8 (5.3%) vs. n = 9 (6.0%) p = 1.00] and R0 resection rate [144 (96.0%) vs. 141 (94.0%), p = 0.607] did not differ between LRPS and ORPS, respectively. The sensitivity analysis showed similar findings in the previous mentioned outcomes. In multivariable regression analysis blood loss was significantly associated with the open approach, higher ASA classification and malignancy as diagnosis. For LOS this was the open approach and a malignancy.

This international multicenter propensity score-matched study showed an advantage in favor of LRPS in selected patients as compared to ORPS in terms of operative time, blood loss and LOS without differences in major complications and R0 resection rate.

ABSTRACT 15

International multicentre propensity score-matched analysis comparing robotic versus laparoscopic right posterior sectionectomy.

Chiow AKH, Fuks D, Choi GH, D'Hondt M, et al. British Journal of Surgery, 2021, 108(12), 1513-1520

ABSTRACT Minimally invasive right posterior sectionectomy (RPS) is a technically challenging procedure. This study was designed to determine outcomes following robotic RPS (R-RPS) and laparoscopic RPS (L-RPS).

An international multicentre retrospective analysis of patients undergoing R-RPS versus those who had purely L-RPS at 21 centres from 2010 to 2019 was performed. Patient demographics, perioperative parameters, and postoperative outcomes were analysed retrospectively from a central database. Propensity score matching (PSM) was performed, with analysis of 1 : 2 and 1 : 1 matched cohorts. Three-hundred and forty patients, including 96 who underwent R-RPS and 244 who had L-RPS, met the study criteria and were included. The median operating time was 295 minutes and there were 25 (7.4 per cent) open conversions. Ninety-seven (28.5 per cent) patients had cirrhosis and 56 (16.5 per cent) patients required blood transfusion. Overall postoperative morbidity rate was 22.1 per cent and major morbidity rate was 6.8 per cent. The median postoperative stay was 6 days. After 1 : 1 matching of 88 R-RPS and L-RPS patients, median (i.q.r.) blood loss (200 (100-400) versus 450 (200-900) ml, respectively; P < 0.001), major blood loss (> 500 ml; P = 0.001), need for intraoperative blood transfusion (10.2 versus 23.9 per cent, respectively; P = 0.014), and open conversion rate (2.3 versus 11.4 per cent, respectively;P = 0.016) were lower in the R-RPS group. Similar results were found in the 1 : 2 matched groups (66 R-RPS versus 132 L-RPS patients).

R-RPS and L-RPS can be performed in expert centres with goodoutcomes in well selected patients. R-RPS was associated with reduced blood loss and lower open conversion rates than L-RPS.

ABSTRACT 16 Minimally invasive liver resection for huge (≥10 cm)

tumors: an international multicenter matched cohort study with regression discontinuity analyses.

Cheung TT, Wang X, Efanov M, D'Hondt M, et al. Hepatobiliary Surgery and Nutrition, 2021, 10(5), 587-597

ABSTRACT The application and feasibility of minimally invasive liver resection (MILR) for huge liver tumours (≥10 cm) has not been well documented.

Retrospective analysis of data on 6,617 patients who had MILR for liver tumours were gathered from 21 international centers between 2009-2019. Huge tumors and large tumors were defined as tumors with a size ≥10.0 cm and 3.0-9.9 cm based on histology, respectively. 1:1 coarsened exact-matching (CEM) and 1:2 Mahalanobis distance-matching (MDM) was performed according to clinically-selected variables. Regression discontinuity analyses were performed as an additional line of sensitivity analysis to estimate local treatment effects at the 10-cm tumor size cutoff.

Of 2,890 patients with tumours ≥3 cm, there were 205 huge tumors. After 1:1 CEM, 174 huge tumors were matched to 174 large tumors; and after 1:2 MDM, 190 huge tumours were matched to 380 large tumours.

There was significantly and consistently increased intraoperative blood loss, frequency in the application of Pringle maneuver, major morbidity and postoperative stay in the huge tumourgroup compared to the large tumour group after both 1:1 CEM and 1:2 MDM. These findings were reinforced in RD analyses. Intraoperative blood transfusion rate and open conversion rate were significantly higher in the huge tumor group after only 1:2 MDM but not 1:1 CEM. MILR for huge tumours can be safely performed in expert centers It is an operation with substantial complexity and high technical requirement, with worse perioperative outcomes compared to MILR for large tumors, therefore judicious patient selection is pivotal.

ABSTRACT 17

Clinical added value of MRI to CT in patients scheduled for local therapy of colorectal liver metastases (CAMINO): study protocol for an international multicentre prospective diagnostic accuracy study.

Görgec B, Hansen I, Lutin B, D'Hondt M, et al. BMC Cancer, 2021, 21(1), 1116

ABSTRACT Abdominal computed tomography (CT) is the standard imaging method for patients with suspected colorectal liver metastases (CRLM) in the diagnostic workup for surgery or thermal ablation. Diffusion-weighted and gadoxetic-acid-enhanced magnetic resonance imaging (MRI) of the liver is increasingly used to improve the detection rate and characterization of liver lesions. MRI is superior in detection and characterization of CRLM as compared to CT. However, it is unknown how MRI actually impacts patient management. The primary aim of the CAMINO study is to evaluate whether MRI has sufficient clinical added value to be routinely added to CT in the staging of CRLM. The secondary objective is to identify subgroups who benefit the most from additional MRI.

In this international multicentre prospective incremental diagnostic accuracy study, 298 patients with primary or recurrent CRLM scheduled for curative liver resection or thermal ablation based on CT staging will be enrolled from 17 centres across the Netherlands, Belgium, Norway, and Italy. All study participants will undergo CT and diffusion-weighted and gadoxetic-acid enhanced MRI prior to local therapy. The local multidisciplinary team will provide two local therapy plans: first, based on CT-staging and second, based on both CT and MRI. The primary outcome measure is the proportion of clinically significant CRLM (CS-CRLM) detected by MRI not visible on CT. CS-CRLM are defined as liver lesions leading to a change in local therapeutical management. If MRI detects new CRLM in segments which would have been resected in the original operative plan, these are not considered CS-CRLM. It is hypothesized that MRI will lead to the detection of CS-CRLM in ≥10% of patients which is considered the minimal clinically important difference.

Furthermore, a prediction model will be developed using multivariable logistic regression modelling to evaluate the predictive value of patient, tumor and procedural variables on finding CS-CRLM on MRI.

The CAMINO study will clarify the clinical added value of MRI to CT in patients with CRLM scheduled for local therapy. This study will provide the evidence required for the implementation of additional MRI in the routine work-up of patients with primary and recurrent CRLM for local therapy.

ABSTRACT 18

ASO author reflections: proposed algorithm for surgical treatment of localized duodenal gist.

Nuytens F, Honoré C, Dubois C Annals of Surgical Oncology, 2021, 28(11), 6307-6308

ABSTRACT Er is geen abstract beschikbaar.

ABSTRACT 19

Incidence and Risk Factors for Diaphragmatic Herniation Following Esophagectomy for Cancer.

Hertault H, Gandon A, Behal H, Nuytens F, et al. Annals of Surgery, 274(5), 2021, 758-765

ABSTRACT The current incidence of DHEC is discussed with conflicting data regarding its treatment and natural course. To evaluate the incidence and risk factors of diaphragmatic herniation following esophagectomy for cancer (DHEC), and assess the results ofsurgical repair.

Monocentric retrospective cohort study (2009-2018). From 902 patients, 719 patients with a complete follow-up of CT scans after transthoracic esophagectomy for cancer were reexamined to identify the occurrence of a DHEC. The incidence of DHEC was estimated using Kalbfleisch and Prentice method and risk factors of DHEC were studied using the Fine and Gray competitive risk regression model by treating death as a competing event. Survival was analyzed. Five-year DHEC incidence was 10.3% [95% CI, 7.8%-13.2%] (n = 59), asymptomatic in 54.2% of cases. In the multivariable analysis, the risk factors for DHEC were: presence of hiatal hernia on preoperative CT scan (HR = 1.72 [1.01-2.94], P= 0.046), previous hiatus surgery (HR = 3.68 [1.61-8.45], P = 0.002), gastroesophageal junction tumor location (HR = 3.51 [1.91-6.45], P < 0.001), neoadjuvant chemoradiotherapy (HR = 4.27 [1.70-10.76], P < 0.001), and minimally invasive abdominal phase (HR = 2.98 [1.60-5.55], P < 0.001). A cure for DHEC was achieved in 55.9%. The postoperative mortality rate was nil, the overall morbidity rate was 12.1%, and the DHEC recurrence rate was 30.3%. Occurrence of DHEC was significantly associated with a lower hazard rate of death in a time-varying Cox's regression analysis (HR = 0.43[0.23-0.81], P = 0.010).

The 5-year incidence of DHEC is 10.3% and is associated with a favorable prognosis. Surgical repair of symptomatic or progressive DHEC is associated with an acceptable morbidity. However, the optimal surgical repair technique remains to be determined in view of the large number of recurrences.

ABSTRACT 20

Risk prediction model of 90-Day mortality after esophagectomy for cancer.

D'Journo XB, Boulate D, Fourdrain A, Nuytens F, et al. JAMA Surgery, 2021, 156(9), 836-845

ABSTRACT Ninety-day mortality rates after esophagectomy are an indicator of the quality of surgical oncologic management. Accurate risk prediction based on large data sets may aid patients and surgeons in making informed decisions. To develop and validate a risk prediction model of death within 90 days after esophagectomy for cancer using the International Esodata Study Group (IESG) database, the largest existing prospective, multicenter cohort reporting standardized postoperative outcomes. In this diagnostic/prognostic study, we performed a retrospective analysis of patients from 39 institutions in 19 countries between January 1, 2015, and December 31, 2019. Patients with esophageal cancer were randomly assigned to development and validation cohorts. A scoring system that predicted death within 90 days based on logistic regression β-coefficients was conducted. A final prognostic score was determined and categorized into homogeneous risk groups that predicted death within 90 days. Calibration and discrimination tests were assessed between cohorts.

A total of 8403 patients (mean [SD] age, 63.6 [9.0] years; 6641 [79.0%] male) were included. The 30-day mortality rate was 2.0% (n = 164), and the 90-day mortality rate was 4.2% (n = 353). Development (n = 4172) and validation (n = 4231) cohorts were randomly assigned. The multiple logistic regression model identified 10 weighted point variables factored into the prognostic score:age, sex, body mass index, performance status, myocardial infarction, connective tissue disease, peripheral vascular disease, liver disease, neoadjuvant treatment, and hospital volume. The prognostic scores were categorized into 5 risk groups: very low risk (score, ≥1; 90-day mortality, 1.8%), low risk (score, 0; 90-day mortality, 3.0%), medium risk (score, -1 to -2; 90-day mortality, 5.8%), high risk (score, -3 to -4: 90-day mortality, 8.9%), and very high risk (score, ≤-5; 90-day mortality, 18.2%). The model was supported by nonsignificance in the Hosmer-Lemeshow test. The discrimination (area under the receiver operating characteristic curve) was 0.68 (95% CI, 0.64-0.72) in the development cohort and 0.64 (95% CI, 0.60-0.69) in the validation cohort.

In this study, on the basis of preoperative variables, the IESG risk prediction model allowed stratification of an individual patient's risk of death within 90 days after esophagectomy. These data suggest that this model can help in the decision-making process when esophageal cancer surgery is being considered and in informed consent.

ABSTRACT 21

Limited resection versus pancreaticoduodenectomy for duodenal gastrointestinal stromal tumors? Enucleation interferes in the debate: a European multicenter retrospective cohort study.

Dubois C, Nuytens F, Behal H Annals of Surgical Oncology, 2021, 28, 6294-6306

ABSTRACT The optimal surgical procedure for duodenal gastrointestinal stromal tumors (D-GISTs) remains poorly defined. Pancreaticoduodenectomy (PD) allows for a wide resection but is associated with a high morbidity rate. The aim of this study was to compare the short- and longterm outcomes of PD versus limited resection (LR) for D-GISTs and to evaluate the role of tumor enucleation (EN).

In this retrospective European multicenter cohort study, 100 patients who underwent resection for D-GIST between 2001 and 2013 were compared betweenPD (n = 19) and LR (n = 81). LR included segmental duodenectomy (n = 47), wedge resection (n = 21), or EN (n = 13). The primary objective was to evaluate disease-free survival (DFS) between the groups, while the secondary objectives were to analyze the overall morbidity and mortality, radicality of resection, and 5-year overall survival (OS) and recurrence rates between groups. Furthermore, the short- and long-term outcomes of EN were evaluated. Baseline characteristics were comparable between the PD and LR groups, except for a more frequent D2 tumor location in the PD group (68.3% vs. 29.6%; p = 0.016). Postoperative morbidity was higher after PD (68.4% vs. 23.5%;p < 0.001). OS (p = 0.70) and DFS (p = 0.64) were comparable after adjustment for D2 location and adjuvant therapy rate. EN was performed more in American Society of Anesthesiologists (ASA) stage III/IV patients with tumors < 5 cm and was associated with a 5-year OS rate of 84.6%, without any disease recurrences.

For D-GISTs, LR should be the procedure of choice due to lower morbidity and similar oncological outcomes compared with PD. In selected patients, EN appears to be associated with equivalent short- and long-term outcomes. Based on these results, a surgical treatment algorithm is proposed. ABSTRACT 22

European society of coloproctology guidance on the use of mesh in the pelvis incolorectal surgery.

Maeda Y, Espin-Basany E, Gorissen K, van Geluwe B, et al. Colorectal Disease, 23(9), 2021, 2228-2285

ABSTRACT This is a comprehensive and rigorous review of currently available data on the use of mesh in the pelvis in colorectal surgery. This guideline outlines the limitations of available data and the challenges of interpretation, followed by best possible recommendations.

ABSTRACT 23

Randomised controlled trial to assess efficacy of pelvic floor muscle training on bowel symptoms after low anterior resection for rectal cancer: study protocol.

Asnong A, D'Hoore A, Van Kampen M, Van Geluwe B, et al. BMJ Open, 2021, 11(1):e041797

ABSTRACT Radical surgery after a total mesorectal excision (TME) for rectal cancer often results in a significant decrease in the patient's quality of life, due to functional problems such as bowel, urinary and sexual dysfunction. The effect of pelvic floor muscle training (PFMT) on these symptoms has been scarcely investigated. We hypothesise that the proportion of successful patients will be significantly higher in the intervention group, receiving 12 weeks of PFMT, compared with the control group without treatment. The primary outcome of this trial is the severity of bowel symptoms, measured through the Low Anterior Resection Syndrome questionnaire, 4 months after TME or stoma closure. Secondary outcomes are related to other bowel and urinary symptoms, sexual function, physical activity and quality of life.

This research protocol describes a multicentre single blind prospective, randomised controlled trial. Since January 2017, patients treated for rectal cancer (n=120) are recruited after TME in three Belgiancentres. One month following surgery or, in case of a temporary ileostomy, 1 month after stoma closure, patients are randomly assigned to the intervention group (n=60) or to the control group (n=60). The assessments concern the preoperative period and 1, 4, 6, 12 and 24 months postoperatively.

ABSTRACT 24

Chapter springer “pelvic floor disorders: a Laparoscopic versus open hemihepatectomy: The ORANGE II PLUS multicenter randomized controlled trial

Fichtinger RS, Aldrighetti L, Troisi R, D'Hondt M, et al. Annals of Oncology, 2021, 32(S5), S531

ABSTRACT Surgical resection forms the mainstay of curative treatment for cancers involving the liver. The laparoscopic approach to major liver resections is increasingly being performed. Randomized evidence to show superiority of laparoscopic (LH) compared to open hemihepatectomy (OH) for perioperative and oncological outcomes is lacking.

Patients undergoing hemihepatectomy for accepted indications (principally known or suspected cancer) were randomized 1:1 to either LH or OH in 16 European centers. Patients and ward personnel were blinded until postoperative day 4. The primary endpoint was time to functional recovery (TFR). The definition included being independently mobile with adequate oral intake and normalizing liver function. Secondary outcomes included length of hospital stay (LOS), postoperative 90-day morbidity, 90-day mortality, resection margin status and 3-year survival. All analyses were by intention to treat (ITT). 179 eligible patients were randomly assigned to LH and 173 to OH between October 2013 and January 2019. 135 (75%) of 179 patients in the LH group and 142 (82%) of 173 patients in the OH group had cancer: 162 colorectal liver metastases (CRLM), 47 hepatoma, 47 cholangiocarcinoma, 21 other metastases.

Primary ITT analysis included 327 patients (LH 164 vs OH 163) and demonstrated a significant reduction in TFR: LH 4 days (IQR 2-6) vs OH 5 days (IQR 3-7), P< 0.001. LOS was similarly different: LH 5 days (IQR 2-8) vs OH 6 days (IQR 4-8), P¼ 0.002. In the LH group 15% (24/164) of patients experienced complications > Clavien-Dindo IIIa within 90 days of surgery vs 18% (30/163) in the OH group, P¼ 0.36. There were 5 deaths (3.0%) within 90 days of surgery in the LH group vs 5 (3.1%) in the OH group, P¼ 0.99. For all cancers, resection margins 1 mm were attained for 107/133 (81%) patients in the LH group vs 121/138 (88%) patients in the OH group (OR 1.73, 99% CI 0.72-4.14, P¼ 0.11). At a median follow-up of 37 months (IQR 24-50 months) 3-year survival rate was 58% for LH vs 65% for OH (HR 1.16, 99% CI 0.68-1.98, P¼0.49). LH is superior to OH in terms of TFR and LOS.

No significant differences in oncological outcomes were observed but follow-up continues to permit a mature survival analysis.

ABSTRACT 25

Outcome of major hepatectomy in cirrhotic patients; does surgical approach matter? A propensity score matched analysis

Benedetti A, Görgec B, Lanari J, D'Hondt M, et al. Journal Hepatobiliary Pancreatic Sciences, 2021, doi: 10.1002/jhbp.1087

ABSTRACT Major hepatectomy in cirrhotic patients still represents a great challenge for liver surgeons. Hence, the aim is to investigate the clinical impact of major hepatectomy and to assess whether the surgical approach influence the outcome of cirrhotic patient.

Multicenter retrospective study including cirrhotic patients undergoing major laparoscopic (mjLLR) and open liver resection (mjOLR) in 14 Western liver centers was performed (2009-2020). Clinical, demographic, and perioperative data were compared using propensity score matching (PSM). Long-term outcome after resection for hepatocellular carcinoma was analyzed.

Overall, 352 patients were included; 108 after mjLLR and 244 after mjOLR. After PSM, 88 patients were matched in each group. In the mjLLR group, compared to mjOLR, less blood loss (p=0.042), lower overall and severe complication (p<0.001, 0.020), such as surgical site infection, acute kidney injury and liver failure were observed, parallel to a shorter length of hospital stay.

Stratifying patients based on the type of resection, less severe complications was observed only after laparoscopic left hepatectomy (p=0.044), while the advantages of laparoscopy tend to decrease during right hepatectomy. Subgroup analysis of long term survivals following liver resection for hepatocellular carcinoma showed no difference between mjLLR and mjOLR.

This multicenter experience suggests potential short-term benefits of mjLLR in cirrhotic patients compared to mjOLR, without compromising long-term outcome. These findings might have interesting clinical implications for the management of patients with chronic liver disease. ABSTRACT 26

Boerhaave's syndrome: successful conservative treatment in two patients.

Van Geluwe B, Van Moerkercke W, Vergauwe P, et al. Acta Gastro-Enterologica Belgica, 2021, 83(4), 654-656

ABSTRACT The Boerhaave syndrome is a spontaneous, post-emetic rupture of the esophagusand a rare but potentially fatal cause of upper gastrointestinal bleeding. There are currently no guidelines on the optimal treatment of these patients, although there is a strong tendency towards a surgical approach. We present 2 cases of male patients, 66- and 77-year old respectively, both admitted to the emergency department with hematemesis. Unexpectedly, these turned out to be caused by the Boerhaave syndrome. Based on the severity of presentation, either a conservative or endoscopic treatment was adopted, both with good outcome.

PRESENTATIES/CONGRESSEN

ABSTRACT 1

Minimal invasive liver resection Implementation: High Complexity procedures

D’Hondt M, Cillo U, Aldrighetti L, Ciria R, Abu Hilal M January 2021, Webcast: Implementation of Minimally Invasive Liver Surgery, Online

ABSTRACT Er is geen abstract beschikbaar.

ABSTRACT 2

The oncological efficiency of laparoscopic liver surgery for colorectal liver me-tastases

D’Hondt M

May, 2021, Webinar International Laparoscopic Liver Society: Minimally Invasive Management of Colorectal Liver Metastasis, Online

ABSTRACT Er is geen abstract beschikbaar.

ABSTRACT 3

Surgical techniques and instrumentation for minimally invasive pancreatectomy

D'Hondt, M

May, 2021, Webcast: European Consortion on Minimally Invansive Pancreatic Surgery (E-MIPS) : Online Mastercourse,Online

ABSTRACT Er is geen abstract beschikbaar.

ABSTRACT 4

A comparative study of an integrated ultrasonic/ bipolar sealing device versus an articulating bipolar sealing device for laparoscopic liver surgery.

D'Hondt M, Provoost A, De Meyere C, Parmentier I, Pottel H, Verslype C

June 2021, 3rd World Congress of International Laparoscopic Liver Society (ILLS), Live Virtual Meeting online

ABSTRACT Hemostatic devices are able to seal and cut tissue with the application of different energy modalities, and are routinely used in open and laparoscopic liver surgery. The aim of this study is to compare the outcome of Thunderbeat (TB) (Olympus Europa Se & Co, Hamburg, Germany), an integrated ultrasonic/bipolar sealing device, versus Enseal (ES) (Ethicon Endo-Surgery Inc., Cincinnati, OH, USA), an articulating bipolar sealing device, in laparoscopic liver surgery.

A retrospective analysis of a prospectively maintained database was conducted in a single supra-regional Belgian center from September 2011 to September 2020. The primary endpoint was evaluation of difference in blood loss between the two hemostatic devices. Secondary endpoints consisted of complications, transfusion rate, operative time, hospital stay, and mortality. Influence of multiple variables was assessed including extension of resection (minor, anatomical major and technical major), laparoscopic liver resection difficulty scores (IWATE and Southampton score), use of cavitron ultrasonic surgical aspirator (CUSA), and application of Pringle maneuver and hemostatic agents.

352 patients were identified who underwent laparoscopic liver surgery, either by using TB (n=105) or ES (n=247). The TB and ES group were comparable in terms of sex, comorbities, extension of resection, and difficulty scores. Median blood loss was significantly higher with TB (50 mL (IQR: [20-120]) compared to ES (100 mL (IQR: [50-250]) (p<0.0001). The amount of blood loss was highest for anatomical major and lowest for minor resections, and increased proportionally with surgical difficulty scores. Use of CUSA was associated with an increase in blood loss in both TB and ES (100 mL (IQR: [50-300]) vs. 175 mL (IQR: [100-400]); p<0.0001). Median operative time was considerably shorter in TB (115 min (IQR: [45-300])) compared to ES (140 min (IQR: [40-370])) (p=0.0008). The Pringle maneuver was more often applied in TB (27.6%) compared to ES (13.8%) (p=0.0036). However, by adjusting for variables influencing blood loss in a generalized linear model, the type of hemostatic device remained a significant contributing factor in blood loss (p=0.0164). The postoperative complication rate was similar for bleeding (TB 0% vs. ES 1.2%; p=0.5574) and biliary leak (TB 1.0% vs. ES 1.6%; p=1.0000), and there was no significant difference in 90-day mortality (TB 0% vs. ES 0.8%; p=1.0000). Median hospital stay was significantly shorter for TB compared to ES (2 days (IQR: [1-4]) vs. 4 days (IQR: [3-6]); p<0.0001) although this might be explained by the introduction of an enhanced recovery after surgery (ERAS) clinical pathway in June 2015.

The integrated ultrasonic/bipolar sealing device is superior compared to the articulating bipolar sealing device in laparoscopic liver surgery in terms of perioperative blood loss without an increase in complications.

ABSTRACT 5

Is there a rapid adaptation in robotic liver surgery for a liver surgeon with a large experience in laparoscopic liver surgery?

D’Hondt M, Devooght A, De Meyere C, Parmentier I, Vandeputte M June 2021, 3rd World Congress of International Laparoscopic Liver Society (ILLS), Live Virtual Meeting online

ABSTRACT Robotic liver surgery (RLS) is currently limited to few highvolume centers. Its reproducibility is still debated. The aim of the present study was to evaluate the results of the first year of robotic liver surgery, performed by an early adopter in laparoscopic liver surgery (LLS) with experience in over 400 laparoscopic cases.

Over a one-year period, 53 patients underwent a robotic hepatectomy. The outcomes of the robotic cases (RG)

were compared to the ‘Initial Experience’-group (IE) of 120 laparoscopic cases, performed by the same surgeon. Subsequently, the robotic series were compared to his last 120 laparoscopic cases or ‘Mastery Phase’-group (MP).

The 3 groups were similar with regards to age, gender, tumor type and Iwate or Southampton difficulty score. Median skin-to-skin operative time of the RG was 140 min versus 130 min in the IE (p=0.026), and 108 min in the MP (p<0.001). Median intraoperative blood loss in the RG was less (40 ml (20-90)) compared to the IE (100 ml (50-250);p<0.001) and the MP (65ml (30-143;p=0.004). Median hospital stay was 3 days in both the RG and MP, versus 5 days in the IE (p<0.001).

There was no significant difference in postoperative complications, conversion or readmission rate. Surgeons with sufficient experience in LLS can rapidly overcome the learning curve for RLS. In our experience, the short-term outcomes of the implementation phase of RLS are similar to the mastery phase of LLS. Blood loss was significantly lower in RLS.

ABSTRACT 6

Establishing minimally invasive liver surgery program

D'Hondt M

June 2021, 3rd World Congress of International Laparoscopic Liver Society (ILLS) , Live Virtual Meeting online

ABSTRACT Er is geen abstract beschikbaar.

ABSTRACT 7

Robotic redo hepatectomy: Resection Sg 4B seven years after open right hemihepatectomy – video presentation

D’Hondt M , Provoost A June, 2021, 3rd World Congress of International Laparoscopic Liver Society (ILLS), Live Virtual Meeting online

ABSTRACT Evidence shows that repeat liver resection is often the best treatment option for recurrent colorectal liver metastases. Although repeat resections can be complex due to adhesion and altered liver anatomy, laparoscopic liver resection has been shown to be feasible in selected patients, and has been associated with shorter operative time, less blood loss, and shorter hospital stay. Compared to laparoscopy, robotic liver surgery has the advantage of 3D visualization and a larger range of motion thanks to endowrist technology. This video aims to demonstrate the first experience of a hepatopancreaticobiliary surgeon with robotic redo hepatectomy. The Pringle maneuver was performed for 18 minutes. Operative time was 170 minutes, and blood loss was 30 cc. Pathology confirmed a R0 resection of the colorectal liver metastasis. There were no intraoperative complications encountered. The postoperative course was uneventful, and the patient was discharged on day 2 post-operatively. Robotic redo hepatectomy is feasible after previous open extensive liver surgery for repeat metastatic liver disease in selected patients.

ABSTRACT 8

Robotic left hemihepatectomy with lymph node dissection for a large intrahepatic cholangiocarcinoma

Willems E, D’Hondt M

June 2021, 3rd World Congress of International Laparoscopic Liver Society (ILLS), Live Virtual Meeting online

ABSTRACT Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver tumor following HCC. The incidence of ICC is low in most parts of the world. However, incidence has been rising. The only curative treatment option involves surgical resection as part of a multidisciplinary treatment. The goal of surgery is to obtain negative section margins while leaving an adequate future liver remnant. The role of regional lymphadenectomy is still debated, as it might add to a higher postoperative morbidity. An expert consensus statement states that regional lymphadenectomy should be considered a standard part of surgical therapy for patients undergoing resection of ICC. Another question remains about the role of minimal invasive surgery for ICC. A laparoscopic approach may lead to lower morbidity without compromising oncological adequacy. However, some doubts remain about the extent of lymph node dissection in laparoscopic approach. This video aims to demonstrate the advantages of a robotic approach using the Da Vinci© XI for left hemihepatectomy with lymph node dissection for a large intrahepatic cholangiocarcinoma. After screening for hepatic of peritoneal metastases, an extensive lymph node dissection of lymph node groups one and two is performed. Hilar structures are divided selectively. Next, a left hemihepatectomy is performed

using the robotic vessel sealer. Finally, the left hepatic vein is divided using a vascular stapler and resection is finished. Operative time was 270 min and blood loss was 20ml. The postoperative course was uneventful and the patient was discharged on postoperative day 3. Pathologic investigation showed an intrahepatic cholangiocarcinoma of 5cm, with tumorfree margins of 17mm. 0/10 lymph nodes were positive. The robotic approach to major hepatectomy with lymph node dissection for intrahepatic cholangiocarcinoma is safe and feasible with an acceptable number of lymph nodes prelevated.

ABSTRACT 9

Belgian prospective registry on laparoscopic liver surgery (brells) compared to open procedures: 3 year snapshot of multicentric activity of open and laparoscopic hepatectomies

Lucidi V, Riva P, D’Hondt M, Vanlander A et al. June 2021, 3rd World Congress of International Laparoscopic Liver Society (ILLS), Live Virtual Meeting online

ABSTRACT Since the International “Louisville Statement” regarding laparoscopic liver surgery in 2009 and further international consensus conferences as the “Morioka recommendations” in 2015 as well as the ‘Southampton consensus guidelines” in 2018 the importance to hold prospective national registries was clearly established. The BReLLS (Belgian Registry on Laparoscopic Liver Surgery) is a prospective, non-compulsory, online registry of laparoscopic (LLS) and open (OLS) liver procedures, endorsed in 2016 by the Belgian Section of Hepato-Biliary and Pancreatic Surgery and approved by ethical committee of all participating centers.

The primary aim is to assess the evolution of laparoscopic liver surgery compared to the standard approach in Belgium. Participating centers included, through a secured SSL server (www.brells.org), all consecutive liver surgeries from 2017 to 2019. Demographic, pre-operative, intra-operative and postoperative (90-day morbidity and follow-up) data of all consecutive LLS and OLS were recorded. In total 13 centers participated to the study, of which 4 Academic hospitals. 1531 procedures were recorded (841 LLS and 690 OLS) in 1408 patients. Demographics of patients were similar between LLS and OLS with a median age of 65 years, gender 60% male, median BMI=26,2 and median ASA score of 2. Indication for surgery were 57% liver metastases (49% LLS, 51% OLS), 29% primary liver tumors (57% LLS, 43% OLS) and 16% benign diseases (73%LLS, 27% OLS). Hepatectomy was performed in 1413 cases and local thermal ablation (LA) in 118 procedures. Excluding LA from analysis, rate of major hepatectomies was 18,2% (n=258) (71 LLS, 187 OLS) and median Ghent difficulty score was 5,6 (4,8 LLS; 6,5 OLS). LLS were converted to OLS in 3,3% of cases.

Overall morbidity was 27% for LLS and 53% for OLS (p<0,001). 90-days mortality following LLS was 0,6% (5/841) and 2,9% (20/690) after OLS (p<0,001). LLS was associated with a shorter length of hospital stay (Median 4 vs 7 days p<0,001).

LLS are wide spreading in Belgium accounting globally to 55% of all liver surgeries. In selected patients, LLS are safe, advantageous and reproducible in major HPB centers. A low morbidity has been prospectively confirmed.

ABSTRACT 10

Establishing a robotic liver surgery program

D'Hondt M

June 2021, 14th Congress of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA),Bilbao – Virtual Webcast

ABSTRACT Er is geen abstract beschikbaar.

ABSTRACT 11

Robotic management of mirizzi syndrome type IV with cholecystocolic fistula: a rare case report

D'Hondt M, Provoost AL June 2021, 14th Congress of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA), Bilbao – Virtual Webcast

ABSTRACT Mirizzi syndrome (MS) is a rare complication of prolonged cholelithiasis, with presence of a large gallstone impacted in Hartman’s pouch, causing chronic extrinsic compression of the common bile duct (CBD), and potentially leading to fistula formation between the gallbladder and the CBD and/ or bowel. Laparoscopic management is widely accepted for MS type I/II, whereas open surgery is the preferred

approach for MS type III/IV and presence of a cholecystoenteric fistula. Robotic surgery has the advantage of 3D visualization and endowrist technology, helping to operate more accurately compared to laparoscopy, and could provide an appropriate alternative surgical approach. This video demonstrates the robotic management of a MS type IV with cholecystocolic fistula.

ABSTRACT 12

Robotic hepaticojejunostomy after open hepaticoduodenostomy

D'Hondt M, Provoost AL June 2021, 14th Congress of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA), Bilbao – Virtual Webcast

ABSTRACT Roux-en-Y hepaticojejunostomy (HJ) is the gold standard to repair iatrogenic bile duct injury. Robotic surgery seems a viable surgical approach, as it permits the sophisticated movements required for anastomotic technique, through 3D visualization, endowrist manipulation and tremor filtration. This video aims to demonstrate a robotic HJ after open hepaticoduodenostomy (HD).

ABSTRACT 13

Robotic central hepatectomy: technical tips and tricks

D'Hondt M, Provoost AL June 2021, 14th Congress of the European-African HepatoPancreato-Biliary Association (E-AHPBA), Bilbao – Virtual Webcast

ABSTRACT Minimal invasive (MI) central hepatectomy is considered a technical complex procedure. The robotic approach could provide benefits over traditional laparoscopy, thanks to 3D visualization, endowrist technology and tremor filtration. Based on three different cases, this video aims to demonstrate technical tips and tricks for robotic central hepatectomy. ABSTRACT 14

Robotic redo hepatectomy: resection SG 4B seven years after open right hemihepatectomy

D'Hondt M, Provoost AL June 2021, Bilbao – Virtual Webcast

ABSTRACT Evidence shows that repeat liver resection is often the best treatment option for recurrent colorectal liver metastases. Although repeat resections can be complex due to adhesion and altered liver anatomy, laparoscopic liver resection has been shown to be feasible in selected patients, and has been associated with shorter operative time, less blood loss, and shorter hospital stay. Compared to laparoscopy, robotic liver surgery has the advantage of 3D visualization and a larger range of motion thanks to endowrist technology. This video aims to demonstrate the experience of a hepatopancreaticobiliary surgeon with robotic redo hepatectomy.

ABSTRACT 15

Robotic pancreas sparing resections for premalignant and neuroendocrine tumors of the pancreas

D'Hondt M, Baekelandt L June 2021, Bilbao – Virtual Webcast

ABSTRACT Our video describes the use of the Da Vinci Surgical System Xi (Intuitive Surgical, Sunnyvale, CA) and application of fluorescence-guided intraoperative ultrasound for minimal invasive tissue sparing pancreas surgery.

ABSTRACT 16

Assessing the impact of minimally invasive liver surgery in the overweight and obese: an international multicenter propensity score matched analysis

Zimmitti G, Sijberden J, Ferrero A, D'hondt M et al. June 2021, Bilbao – Virtual Webcast

ABSTRACT Despite the worldwide increase of obesity prevalence and widespread expansion of minimally invasive liver surgery (MILS), the safety and efficacy of MILS in obese patients is still a matter of debate. The aim of this study is to investigate possible advantages of MILS over open liver surgery (OLS) among patients with different classes of bodyweight.

ABSTRACT 17

Robotic left hemihepatectomy with lymph node dissection for a large intrahepatic cholangiocarcinoma

Willems E, D'Hondt M June 2021, Bilbao – Virtual Webcast

ABSTRACT Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver tumor following HCC. The incidence of ICC is low in most parts of the world. However, incidence has been rising. The only curative treatment option involves surgical resection as part of a multidisciplinary treatment. The goal of surgery is to obtain negative section margins while leaving an adequate future liver remnant. The role of regional lymphadenectomy is still debated, as it might add to a higher postoperative morbidity. An expert consensus statement states that regional lymphadenectomy should be considered a standard part of surgical therapy for patients undergoing resection of ICC. Another question remains about the role of minimal invasive surgery for ICC. A laparoscopic approach may lead to lower morbidity without compromising oncological adequacy. However, some doubts remain about the extent of lymph node dissection in laparoscopic approach. This video aims to demonstrate the advantages of a robotic approach using the Da Vinci© XI for left hemihepatectomy with lymph node dissection for a large intrahepatic cholangiocarcinoma.

ABSTRACT 18

Robotic biliary surgery for benign and malignant bile duct obstruction

D'Hondt M, Wicherts D June 2021, Bilbao – Virtual Webcast

ABSTRACT The majority of patients with benign or malignant biliary obstruction require surgical treatment with a bilio-enteric anastomosis. This requires fine dissection and advanced suturing. Robotic surgery may overcome some major limitations of conventional laparoscopic surgery. The precise role of robotic biliary surgery is however still to be defined. ABSTRACT 19

Benefits of laparoscopy for major liver resection in cirrhotic patients: time for pushing indications beyond the limits? A propensity score matched analysis

Benedetti Cacciaguerra A, Görgec B, Lanari J, D'Hondt M, et al. June 2021, Bilbao – Virtual Webcast

ABSTRACT Despite an increasing use of laparoscopy for liver resection in cirrhotic patients, clear evidence of its advantage over the open approach in major liver resection is still lacking. The aim of this study is to compare the outcomes of major laparoscopic liver resection (mjLLR) and major open liver resection (mjOLR) in cirrhotic patients.

ABSTRACT 20

First year of the european registry for minimally invasive pancreatic surgery (E-MIPS)

van der Heijde N, Vissers F, Manzoni A, D'Hondt M, et al. June 2021, Bilbao – Virtual Webcast

ABSTRACT The European registry for minimally invasive pancreatic surgery (E-MIPS) collects data on laparoscopic and robotic MIPS procedures in all low- and high-volume centers across Europe. The aim is to monitor and report on safety and quality outcomes of MIPS in daily clinical practice. Pancreatic surgery is known for high postoperative morbidity rates. The minority of these procedures is done through a minimally invasive approach.

ABSTRACT 21

Bile leakage after laparoscopic and open liver tesection; incidence and clinical impact: an international multicenter propensity score-matched study of 13,379 patients

Görgec B, Benedetti Cacciaguerra A, Cipriani F, D'Hondt M, et al. June 2021, Bilbao – Virtual Webcast

ABSTRACT Despite many developments, postoperative bile leakage (POBL) remains a relatively common postoperative complication after laparoscopic liver resection (LLR) and open liver

resection (OLR). Previous studies regarding the incidence and clinical impact of POBL have mainly focused on patients undergoing OLR. The aim of this study is to compare the incidence and clinical impact of POBL between patients undergoing LLR and OLR in a large international multicenter cohort using a propensity score matched analysis.

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Robotic two-stage hepatectomy: tight hemihepatectomy after segment 4B resection and right portal vein embolisation

Heazntjes L, D'Hondt M June 2021, Bilbao – Virtual Webcast

ABSTRACT Two-stage liver surgery is a valid option for the treatment of bilobar colorectal liver metastasis (CRLMs) and offers a chance of cure. This video demonstrates technical aspects of a two-stage robotic hepatectomy for bilateral CRLMs.To our knowledge, this is the first video of a two-stage robotic liver resection.

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The basics in laparoscopic liver surgery are also essentials: Patients selection and preoperative investigations

D'Hondt M

April 2021, Online

ABSTRACT Er is geen abstract beschikbaar.

ABSTRACT 24

Technology in laparoscopic liver surgery: the best use of intraoperative ultrasound in laparoscopic liver surgery

D'Hondt M

May, 2021, Online

ABSTRACT Er is geen abstract beschikbaar ABSTRACT 25

Minor liver resections are still major surgical procedures: Left lateral secionectomy, the golden standard

D'Hondt M

June 2021, Online

ABSTRACT Er is geen abstract beschikbaar.

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Complications in Laparoscopic liver surgery : Prevention of complication in Laparoscopic liver surgery

D'Hondt M

July 2021, Online

ABSTRACT Er is geen abstract beschikbaar.

ABSTRACT 27

Parenchyma sparing laparoscopic liver resections : parenchyma sparing liver resection in the posterior segments

D'Hondt M

September 2021, Online

ABSTRACT Er is geen abstract beschikbaar.

ABSTRACT 28

Robotic liver surgery: video session

D'Hondt M

October 2021, Online

ABSTRACT Er is geen abstract beschikbaar.

ABSTRACT 29

Major laparoscopic liver resections: central liver resections

D'Hondt M

November 2021, Online

ABSTRACT Er is geen abstract beschikbaar.

ABSTRACT 30

Pushing boundaries in laparoscopic liver surgery. Complex laparoscopic parenchymal sparing resections for bilobar colorectal liver metastases

D'Hondt M

December 2021, Online

ABSTRACT Er is geen abstract beschikbaar.

ABSTRACT 31

How to start and implement a robotic program

D'Hondt M

December, 2021, Online

ABSTRACT Er is geen abstract beschikbaar.

ABSTRACT 32

Minimal invasive liver resection Implementation: high complexity procedures

Aldrighetti L, Abu Hilai M, D’Hondt M, et al. Januari 2021, webinar : project of training and implementation in minimally invasive liver surgery : complex settings, Milan, Italy

ABSTRACT Er is geen abstract beschikbaar.

ABSTRACT 33

Is there a rapid adaptation in robotic liver surgery for a liver surgeon with a large experience in laparoscopic liver surgery?

D’Hondt M, Devooght A, De Meyere C, Parmentier I, Vandeputte M June 2021, 3rd World Congress of International Laparoscopic Liver Society (ILLS), Live Virtual Meeting online

ABSTRACT Robotic liver surgery (RLS) is currently limited to few highvolume centers. Its reproducibility is still debated. The aim of the present study was to evaluate the results of the first year of robotic liver surgery, performed by an early adopter in laparoscopic liver surgery (LLS) with experience in over 400 laparoscopic cases. Over a one-year period, 53 patients underwent a robotic hepatectomy. The outcomes of the robotic cases (RG) were compared to the ‘Initial Experience’-group (IE) of 120 laparoscopic cases, performed by the same surgeon. Subsequently, the robotic series were compared to his last 120 laparoscopic cases or ‘Mastery Phase’-group (MP). The 3 groups were similar with regards to age, gender, tumor type and Iwate or Southampton difficulty score. Median skin-to-skin operative time of the RG was 140 min versus 130 min in the IE (p=0.026), and 108 min in the MP (p<0.001). Median intraoperative blood loss in the RG was less (40 ml (20-90)) compared to the IE (100 ml (50-250);p<0.001) and the MP (65ml (30-143;p=0.004). Median hospital stay was 3 days in both the RG and MP, versus 5 days in the IE (p<0.001). There was no significant difference in postoperative complications, conversion or readmission rate. Surgeons with sufficient experience in LLS can rapidly overcome the learning curve for RLS. In our experience, the short-term outcomes of the implementation phase of RLS are similar to the mastery phase of LLS. Blood loss was significantly lower in RLS.