Gallbladder, Bile Duct and Pancreas Disorders: Current Challenges, New Perspectives and Innovative Techniques

Background and Objectives: Bile duct injury is a relatively rare, but critical complication of laparoscopic cholecystectomy and is most commonly attributed to misinterpretation of biliary anatomy. Intraoperative biliary imaging may enhance anatomical recognition and reduce operative uncertainty, yet the optimal imaging modality remains debated. This study aimed to compare conventional intraoperative X-ray cholangiography with two fluorescence-based techniques—intravenous and intracholecystic indocyanine green fluorescence cholangiography—with respect to biliary visualization, perioperative outcomes, and surgeon satisfaction during elective laparoscopic cholecystectomy. Materials and Methods: This prospective, single-center, single-blind randomized controlled trial included 240 adult patients scheduled for elective laparoscopic cholecystectomy between June 2021 and December 2022. Participants were randomized equally to standard intraoperative cholangiography, intravenous indocyanine green fluorescence cholangiography, or intracholecystic indocyanine green fluorescence cholangiography. The primary outcome was successful visualization of predefined extrahepatic biliary landmarks, including the critical junction. Secondary outcomes included cholangiography duration, perioperative complications, postoperative inflammatory markers, and surgeon satisfaction assessed using a five-point Likert scale. This study was registered at ClinicalTrials.gov (NCT04908826). Results: Visualization rates of the critical junction and major extrahepatic bile ducts were comparable among three groups, with no statistically significant differences observed. Both fluorescence-based techniques achieved a 100% technical success rate, whereas standard cholangiography failed in a small proportion of cases. Cholangiography duration was significantly shorter in the fluorescence groups compared with standard cholangiography (p < 0.001). Surgeon satisfaction scores were significantly higher for both fluorescence approaches, with a slight preference for intravenous administration. Perioperative complication rates and postoperative inflammatory markers were com-parable among groups. Conclusions: Intravenous and intracholecystic indocyanine green fluorescence cholangiography are non-inferior to conventional intraoperative cholangiography for biliary anatomy visualization and offer advantages in procedural efficiency and surgeon satisfaction. Fluorescence-based imaging represents a safe and effective alternative for intraoperative biliary mapping during elective laparoscopic cholecystectomy. Full article

Background and Objectives: Pancreatoduodenectomy (PD) is the primary treatment for patients with resectable, non-metastatic pancreatic adenocarcinoma and periampullary tumors. Although surgical methods and perioperative management have improved, the procedure still carries a high risk of complications, with postoperative pancreatic fistula (POPF) being the most significant. This study focuses on identifying current risk factors for POPF after PD in a single HPB center. Materials and Methods: We retrospectively analyzed prospectively collected data from patients undergoing PD in our department between October 2018 and April 2024. Data included demographics, comorbidities, lifestyle factors, preoperative tests (bilirubin, CA19-9, HbA1c), intraoperative variables (pancreatic texture, duct diameter), and postoperative outcomes. POPF was classified using the International Study Group of Pancreatic Surgery (ISGPS) criteria. Univariate and multivariate logistic regression analyses were performed. Results: A total of 118 patients underwent PD (82 males, 36 females; mean age 67 (45–85) years; mean body mass index (BMI) 26.6 kg/m²). POPF occurred in 37 patients (31%), with 27 Grade B (23%) and 10 Grade C (9%). The 30- and 90-day mortality rates were 5% and 12.7%, respectively. Univariate analysis showed associations between POPF and soft pancreas (p = 0.018), c-reactive protein (CRP) on postoperative day (POD) 5 (p = 0.004), and serum amylase on POD 0 (p = 0.008). Diabetes mellitus was associated with a lower incidence of POPF (p = 0.014). Multivariate analysis confirmed CRP on POD 5 (OR 1.007, p = 0.025) and DM (OR 0.254, p = 0.015), as independent factors. ROC analysis identified POD 0 amylase >113.5 U/L (AUC 0.717) and POD 5 CRP >125.3 mg/dL (AUC 0.669) as predictive values. Conclusions: POPF remains an important complication after PD. CRP > 126 mg/dL on POD 5 was associated with POPF and may serve as an adjunctive signal to guide further assessment, including imaging. The observed inverse association with diabetes mellitus is hypothesis-generating and should be interpreted cautiously, considering potential confounding and the influence of center volume, surgeon heterogeneity, and institutional protocols. Full article

Background and Objectives: Laparoscopic cholecystectomy constitutes the current “gold standard” treatment of symptomatic gallstone disease. In order to avoid intraoperative vasculobiliary injuries, it is mandatory to establish the “critical view of safety”. In cases of poor identification of the cystic duct and artery leading to a missed intraoperative injury, patients present with elevated liver function tests (LFTs) or increased bilirubin postoperatively. The aim of this study is to present a series of patients of our institute with elevated liver enzymes and bilirubin after laparoscopic cholecystectomy in the absence of intraoperative injury or any other obvious etiology and to provide a possible explanation of this finding. Materials and Methods: From 2019 to 2023, 200 patients underwent elective laparoscopic cholecystectomy at the Papageorgiou General Hospital and at the European Interbalkan Medical Center of Thessaloniki utilizing the “critical view of safety” method. We retrospectively collected the intraoperative reports, and the pre- and postoperative imaging and laboratory studies of the patients included in this series. Postoperative LFTs and bilirubin levels were extracted and the reason for their transient elevation was examined. Results: From 200 cases of laparoscopic cholecystectomy, elevated LFTs and bilirubin were found in six patients on the first postoperative day, which is suggestive of a missed intraoperative injury. All patients were asymptomatic. During the investigatory workup, a triple-phase CT of the liver and/or an MRCP were ordered, but no pathological findings, such as biliary injury, hepatic artery injury or choledocholithiasis, were found. On postoperative day 3, LFTs and bilirubin levels decreased or normalized without any intervention. No postoperative complications were reported. Conclusions: In select cases, a transient increase in LFTs and/or bilirubin may be observed in the early postoperative period after elective laparoscopic cholecystectomy in the absence of an obvious etiology. A possible interpretation of these findings could involve the pneumoperitoneum or the anesthesia regimens used intra- or perioperatively. The specific cause, however, remains undetermined and yet to be examined by future studies. Full article

Background and Objectives: Biliary fistulas (BFs) occur in approximately 3–8% of patients undergoing pancreaticoduodenectomy (PD), and the bile duct diameter ≤ 5 mm is the most important risk factor. The aim of this study was to evaluate the efficacy of biodegradable biliary stents (BSs) in reducing complications in patients undergoing robotic pancreaticoduodenectomy (RPD) with a bile duct diameter of ≤5 mm. Materials and Methods: A retrospective single-centre observational study was conducted. Patients undergoing RPD after the completion of the robotic biliary anastomosis learning curve were included in this study. Only patients with a bile duct diameter ≤ 5 mm were included in the analysis. A prospectively held database was used. The intraoperative time for biliary anastomosis was extracted from surgical videos. Results: Of 30 patients, 20 received no biliary stent (nBS) and 10 received a biodegradable stent (BS). The decision to use a stent was based on product availability. The median operative time for biliary anastomosis was significantly shorter in the BS group compared to the nBS group, at 15 min versus 24 min (p < 0.001). Three patients in the nBS group developed a BF, whereas none were observed in the BS group. No stent migration was observed in any of the patients. Conclusions: The use of biodegradable biliary stents in high-risk biliary anastomosis in RPD appears to effectively reduce the incidence of BFs and may serve as a viable strategy to mitigate early biliary complications. The use of biodegradable stents facilitates a faster and easier biliary anastomosis. These findings suggest a potential benefit of using biodegradable stents in complex biliary reconstruction. However, larger studies are needed to confirm these results. Full article

Malignant biliary obstruction is commonly treated with biliary stenting either endoscopically or percutaneously; however, tumor ingrowth might occlude the stent, often leading to recurrent jaundice and repeat interventions. Endobiliary microwave ablation (MWA) is an emerging adjunct intended to devitalize intraductal tumors and potentially prolong stent patency. This review assesses the state of the art of endobiliary ablation for malignant biliary obstruction, focusing on the technique and safety of percutaneous procedures, as well as patient outcomes. It also discusses the use of flexible endobiliary MWA for hilar cholangiocarcinoma. The review covers ablation methods such as radiofrequency and MWA, which can be performed endoscopically or percutaneously. Research indicates that endobiliary thermal ablation is technically feasible and can be safely combined with stenting. Some studies suggest it may prolong stent patency and decrease the necessity for repeat procedures compared with stenting alone. Percutaneous techniques may be particularly helpful in complex hilar cases, allowing accurate energy delivery, protection of secondary bile ducts, and tailored stent placement. New microwave systems can heat tissue more deeply and evenly than radiofrequency ablation, which may improve local tumor control. Endobiliary thermal ablation appears to be a useful supplement to stenting, especially for patients with unresectable hilar cholangiocarcinoma. Flexible percutaneous MWA probes could make this treatment more widely available. Still, more high-quality studies are needed to find optimal ablation settings, identify which patients benefit most, and compare this method with standard stenting. Full article

Background and Objectives: Posthepatectomy liver failure (PHLF) remains a major cause of morbidity and mortality for patients undergoing major liver resections. Recent research highlights the expanding role of machine learning (ML), a crucial subfield of artificial intelligence (AI), in optimizing risk stratification. The aim of the current study was to review, elaborate on and critically analyze the available literature regarding the use of ML-driven risk prediction models for posthepatectomy liver failure. Materials and Methods: A systematic search was conducted in the PubMed/MEDLINE, Scopus and Web of Science databases. Fifteen studies that trained and validated ML models for prediction of PHLF were further included and analyzed. Results: The available literature supports the value of ML-derived models for PHLF prediction. Perioperative clinical, laboratory and imaging features have been combined in a variety of different algorithms to provided interpretable and accurate models for identifying patients at risk of PHLF. The ML-based algorithms have consistently demonstrated high area under the curve and sensitivity values, surpassing traditionally used risk scores in predictive performance. Limitations include the small sample sizes, heterogeneity in populations included, lack of external validation and a reported poor ability to distinguish between true positive and false positive cases in several studies. Conclusions: Despite the constraints, ML-driven tools, in combination with traditional scoring systems and clinical insight, may enable early and accurate PHLF risk detection, personalized surgical planning and optimization of postoperative outcomes in liver surgery. Full article

Hepatectomies play a crucial role in the multidisciplinary management of primary and secondary liver malignancies but are associated with significant risks, including 30-day mortality, morbidity, prolonged hospitalization, and increased resource utilization. Optimizing perioperative care remains a challenge; however, enhanced recovery programs have shown improved patient outcomes. The EUPEMEN (EUropean PErioperative MEdical Networking) protocol focuses on improving the perioperative management of liver resections through the establishment of interdisciplinary principles based on practical experience and theoretical frameworks from five European countries. This paper outlines the core elements of the EUPEMEN protocol, emphasizing strategies to minimize surgical stress, optimize perioperative care, and enhance postoperative recovery. The protocol is systematically designed to reduce postoperative mortality and morbidity, shorten hospital stays, and improve patient outcomes. The EUPEMEN guidelines address inconsistencies in surgical practice across Europe and are structured for implementation in various healthcare environments. “The protocol’s approach is designed to support improvements in perioperative care standards in liver resections and may serve as a practical and efficient tool for healthcare professionals, pending further clinical validation. The EUPEMEN protocol offers a standardized, evidence-based framework to enhance perioperative management in hepatectomies. By integrating multidisciplinary principles, the main target is to eliminate complications, improve surgical outcomes, and promote faster recovery. Its implementation across diverse clinical settings may contribute to advancing perioperative care standards for liver resections in Europe. Full article

Introduction: Acute necrotizing pancreatitis (ANP) is the acute inflammation of pancreatic parenchyma, most commonly due to alcohol abuse or cholelithiasis. The treatment can be either conservative or invasive, including a variety of techniques; however, it has not yet been established if the intervention should be early or if it should be delayed. The aim of this review is to investigate the optimal time for intervention in ANP. Methods: A literature search was conducted in PubMed and Scopus from inception until September 2024 for studies reporting the comparison between early and late intervention. Results: Early intervention, within 4 weeks of symptom onset, often involves drainage via percutaneous, endoscopic, or combined methods. Delayed intervention occurs after 4 weeks of symptom onset. This can be conducted either surgically or via minimally invasive means. The results of this review reveal that the time of intervention for ANP plays an important role in the prognosis and the course of the disease. In particular, early intervention is associated with higher mortality, which is also the primary clinical outcome. Delayed intervention is also superior regarding secondary clinical outcomes, specifically the complications associated with the intervention. Thus, it is accompanied by fewer episodes of new-onset organ failure, bleeding, gastrointestinal fistula, pancreatic fistula, wound infection, endocrine pancreatic insufficiency, and other complications. Finally, delayed intervention results in shorter stays, both in hospitals and the ICU. Conclusions: Delayed intervention is clearly more effective than early intervention and should be preferred. However, early intervention appears to be both safe and effective, and it is feasible. Full article

Hepatobiliary ascariasis is caused by the entry of the nematode A. lumbricoides from the duodenum into the biliary duct. We report a case of an Ascaris-induced extrahepatic biliary tract obstruction in a pediatric patient admitted to the hospital due to a wide spectrum of symptoms of biliary disease, which included abdominal pain in the upper abdominal quadrants, vomiting, and jaundice. Imaging tests—including ultrasound, magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP)—were performed to confirm the diagnosis of biliary ascariasis. The tests did, in fact, demonstrate signs of this disease. Nevertheless, during the ERCP, only the remains of Ascaris parasites in the form of tissue fragments were extracted. We also aim to discuss the prevalence of ascariasis in children, the causes of migration of Ascaris parasites into the bile ducts, together with its clinical manifestations, as well as the diagnostic and treatment methods of this disease. Full article

Background and Objectives: Scrotal swelling or hydrocele is a rare complication of acute pancreatitis described in the literature. We present a case of penoscrotal swelling caused by the first attack of acute interstitial edematous alcohol-induced pancreatitis in a young male patient. Case report: A 22-year-old man was admitted to the emergency unit due to diarrhea and vomiting since morning which was followed by severe abdominal pain. Urgent abdominal multislice CT scan showed steatosis, pancreatic swelling and acute peripancreatic fluid collection (interstitial edematous pancreatitis). Also, scan showed fluid between small bowel loops and along the anterior renal fascia, while there was minimal amount of fluid in the Douglas space. There was no sign of penoscrotal swelling. On the second day of admission, the patient developed left scrotal swelling and mild pain without erythema. On the fourth day, a control CT scan showed progression to moderately severe pancreatitis (CT severity index 4). Dilated scrotal veins of the pampiniform venous plexus with an increased caliber of the testicular veins were present on both sides, from the scrotum to the level of the inguinal canal. Penoscrotal swelling was significantly reduced on discharge. Conclusions: Penoscrotal swelling is a rare complication or manifestation of acute inflammation of the pancreas. It is important to identify scrotal swelling caused by pancreatitis because in severe cases it can be related to possible infertility in the future. Full article

Background and Objectives: The pancreas, ensconced within the abdominal cavity, requires a plethora of sophisticated imaging modalities for its comprehensive evaluation, with ultrasonography serving as a primary investigative technique. A myriad of pancreatic pathologies, encompassing pancreatic neoplasia and a spectrum of inflammatory diseases, are detectable through these imaging strategies. Nevertheless, the intricate anatomical confluence and the pancreas’s deep-seated topography render the visualization and accurate diagnosis of its pathologies a formidable endeavor. The objective of our paper is to review the best diagnostic imagistic tools for the pancreas. Materials and Methods: we have gathered several articles using Prisma guidelines to determine the best imagistic methods. The imperative of pancreatic scanning transcends its diagnostic utility, proving to be a pivotal element in a multitude of clinical specialties, notably surgical oncology. Within this domain, multidetector computed tomography (MDCT) of the pancreas holds the distinction of being the paramount imaging modality, endorsed for its unrivaled capacity to delineate the staging and progression of pancreatic carcinoma. In synergy with MDCT, there has been a notable advent of avant-garde imaging techniques in recent years. These advanced methodologies, including ultrasonography, endoscopic ultrasonography, contrast-enhanced ultrasonography, and magnetic resonance imaging (MRI) conjoined with magnetic resonance cholangiopancreatography (MRCP), have broadened the horizon of tumor characterization, offering unparalleled depth and precision in oncological assessment. Other emerging diagnostic techniques, such as elastography, also hold a lot of potential and promise for the future of pancreatic imaging. Fine needle aspiration (FNA) is a quick, minimally invasive procedure to evaluate lumps using a thin needle to extract tissue for analysis. It is less invasive than surgical biopsies and usually performed as an outpatient with quick recovery. Its accuracy depends on sample quality, and the risks include minimal bleeding or discomfort. Results, guiding further treatment, are typically available within a week. Elastography is a non-invasive medical imaging technique that maps the elastic properties and stiffness of soft tissue. This method, often used in conjunction with ultrasound or MRI, helps differentiate between hard and soft areas in tissue, providing valuable diagnostic information. It is particularly useful for assessing liver fibrosis, thyroid nodules, breast lumps, and musculoskeletal conditions. The technique is painless and involves applying gentle pressure to the area being examined. The resulting images show tissue stiffness, indicating potential abnormalities. Elastography is advantageous for its ability to detect diseases in early stages and monitor treatment effectiveness. The procedure is quick, safe, and requires no special preparation, with results typically available immediately. Results: The assembled and gathered data shows the efficacy of various techniques in discerning the nature and extent of neoplastic lesions within the pancreas. Conclusions: The most common imaging modalities currently used in diagnosing pancreatic neoplasms are multidetector computed tomography (MDCT), endoscopic ultrasound (EUS), and magnetic resonance imaging (MRI), alongside new technologies, such as elastography. Full article