Background: Despite the significant advancements of liver surgery in the last few decades, the survival rate of patients with liver and pancreatic cancers has improved by only 10% in 30 years. Precision medicine offers a patient-centered approach, which, when combined with machine learning, could enhance decision making and treatment outcomes in surgical management of ihCC. This study aims to develop a decision support model to optimize treatment strategies for patients with ihCC, a prevalent primary liver cancer. Methods: The decision support model, named MedMax, was developed using three data sources: studies retrieved through a systematic literature review, expert opinions from HPB surgeons, and data from ihCC patients treated at Heidelberg University Hospital. Expert opinions were collected via surveys, with factors rated on a Likert scale, while patient data were used to validate the model’s accuracy. Results: The model is structured into four decision-making phases, assessing diagnosis, treatment modality, surgical approach, and prognosis. Prospectively, 44 patients with ihCC were included for internal primary validation of the model. MedMax could predict the appropriate treatment considering the resectability of the lesions in 100% of patients. Also, MedMax could predict a decent surgical approach in 77% of the patients. The model proved effective in making decisions regarding surgery and patient management, demonstrating its potential as a clinical decision support tool. Conclusions: MedMax offers a transparent, personalized approach to decision making in HPB surgery, particularly for ihCC patients. Initial results show high accuracy in treatment selection, and the model’s flexibility allows for future expansion to other liver tumors and HPB surgeries. Further validation with larger patient cohorts is required to enhance its clinical utility.

Portal vein arterialization (PVA) is a surgical procedure that plays a crucial role in hepatic vascular salvage when hepatic artery flow restoration remains elusive. Dedicated diagnostic vascular imaging and the timely management of PVA shunts are paramount to preventing complications, such as portal hypertension and thrombosis. Regrettably, a lack of standardized postoperative management protocols for PVA has increased morbidity and mortality rates post-procedure. In response to this challenge, we developed a PVA standard operating procedure (SOP) tailored to the needs of interventional radiologists. This SOP is designed to harmonize postoperative care, fostering scientific comparability across cases. This concise brief report aims to offer radiologists valuable insights into the PVA technique and considerations for post-PVA care and foster effective interdisciplinary collaboration.

Background: Portal vein resection (PVR) extends curative-intent surgery for locally advanced perihilar cholangiocarcinoma (pCCA). However, whether PVR independently affects perioperative and long-term outcomes remains unclear. This study evaluated the impact of PVR on outcomes after major hepatectomy for pCCA in a single-center experience. Methods: Overall, 171 consecutive patients who underwent single-stage curative-intent major hepatectomy for pCCA between 2003 and 2023 were analyzed, of whom 34 (19.9%) underwent PVR. Factors associated with 90-day mortality were analyzed by penalized logistic regression. Overall survival (OS) was analyzed in all 171 patients, including postoperative deaths, by Kaplan–Meier and Cox regression, and in 90-day survivors as a secondary landmark analysis. Results: The in-hospital mortality was 14.7% after PVR and 8.0% without PVR (p = 0.319). The 90-day mortality was 17.6% and 13.9% (p = 0.591); it was associated with age (OR 1.05 per year, p = 0.021) and extended hepatectomy (OR 3.92, p = 0.002), whereas no statistically significant association with PVR was detected (OR 1.31, 95% CI 0.43–3.62). Median OS was 15.4 months after PVR and 33.9 months without PVR (5-year OS 17.2% vs. 33.8%; p = 0.009), and PVR was associated with shorter OS after adjustment (HR 1.75, 95% CI 1.09–2.79). Among 90-day survivors, this association was weaker and not statistically significant (HR 1.54, 95% CI 0.85–2.78). Conclusions: PVR was not significantly associated with 90-day mortality, which was associated with age and the extent of hepatectomy. PVR was associated with shorter OS, whereas the association among 90-day survivors was weaker and statistically uncertain. When technically feasible, PVR may be considered to achieve a curative resection in carefully selected patients, with particular attention to age and the extent of the planned hepatectomy.

Background: Bile leakage remains a significant challenge following major liver resection, with potential for improvement depending on the transection technique used. In this study, we aimed to evaluate the effectiveness of our hybrid resection technique—utilizing both LigaSure and stapler devices—in reducing bile leakage after major liver resection compared to our conventional stapler-only technique. As a secondary aim, we compared overall morbidity, costs, and reimbursements. Method: Patients who underwent major hepatectomy without biliary reconstruction using either the hybrid or stapler technique between August 2014 and December 2021 were included in the study. Propensity score matching was performed using a one-to-two algorithm. Perioperative data, bile leakage rates, and cost and reimbursement information based on the diagnosis-related group (DRG) system were analyzed. Results: In total, data from 492 patients were evaluated (hybrid = 152; stapler = 340). After one-to-two propensity score matching, the operation time was significantly longer in the hybrid group (p = 0.005). A cost analysis showed no significant difference in total operative costs between the two techniques (p = 0.092). However, the hybrid group had a significantly lower rate of bile leakage (p = 0.002), as well as shorter intensive care unit (ICU) and overall hospital stays (p = 0.034 and p = 0.007, respectively). Consequently, ICU and ward costs were significantly lower in the hybrid group (p = 0.024 and p = 0.014, respectively) compared to the stapler group. The financial difference calculated as DRG reimbursement minus costs was two-fold higher in the hybrid group (p = 0.02). Conclusions: Although the hybrid technique resulted in a longer operating time, it proved superior to the stapler technique in reducing postoperative bile leakage and shortening ICU and hospital stays. Furthermore, the use of the hybrid technique was more cost efficient and resulted in a greater positive financial margin.

Background: Intrahepatic cholangiocarcinoma (ihCC) is a rare aggressive liver malignancy with rising incidence. For resectable cases, surgery is the only curative approach, but recurrence rates remain high. These challenges highlight the need for personalized, evidence-based clinical decision-making to improve patient outcomes. To address this, we developed the Multiphasic Evidential Decision-making Matrix (MedMax) to support systematic, individualized therapeutic strategies for ihCC. Methods: In this retrospective single-center study, between 2010 and 2020, we assessed the ability of the MedMax matrix to make treatment decisions in 489 consecutive patients with ihCC or suspected ihCC. Patients were divided into two cohorts depending on whether their tumor was operable (surgical cohort, n = 335) or non-operable (non-surgical cohort, n = 154). We assessed the accuracy of diagnostic confirmation and treatment allocation by MedMax and evaluated how the model’s recommendations corresponded to those made by the tumor board. Results: In the surgical cohort, MedMax achieved 100% accuracy in diagnostic confirmation and 97.9% accuracy in treatment allocation. There was 74.3% concordance between the resection type proposed by MedMax and actual extent of resection. This discrepancy was caused by deviations from the preoperative plan based on intraoperative findings, which could not have been predicted preoperatively. In the non-surgical cohort, MedMax again achieved 100% accuracy in diagnostic confirmation and 98.7% accuracy in treatment allocation. All discrepancies between the decisions made by MedMax and those made by the tumor board were attributed complex, high-risk patient profiles. MedMax reliably identified risk factors (such as advanced comorbidities and multifocal disease) in both cohorts. Conclusions: The MedMax matrix can make accurate, reliable and transparent decisions about the diagnosis and treatment of patients with ihCC thanks to its modular, evidence-based approach. It can also stratify and document risks in both surgical and non-surgical settings.