Whether the Liver-to-Portal Vein Ratio is Applicable for Evaluating the European Society of Gastrointestinal and Abdominal Radiology Hepatobiliary Phase in Gd-EOB-DTPA-Enhanced MRI?

PURPOSE: This study aimed to verify whether the Liver-to-portal Ratio (LPR) can assess the adequacy of the Hepatobiliary Phase (HBP) for patients with different liver functions. METHODS: A total of 125 patients were prospectively enrolled in the study and graded into the non-cirrhosis group (45), Child-Pugh A group (40), and Child- Pugh B/C group (40). The LPR on HBP was calculated after eight HBPs were obtained within 5-40 minutes. The adequate HBP was determined according to the 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus statement. The differences in LPR and lesions' conspicuity between 10-min HBP and adequate HBP were analyzed by paired t-test and Wilcoxon signed-rank test, respectively. The chisquare test was used to test the difference in proportion with LPR larger than 1.462 between 10-min HBP and adequate HBP. RESULTS: The differences in LPR and lesions' conspicuity between 10-min HBP and adequate HBP were significant in Child-Pugh A and Child-Pugh B/C groups (P < 0.05), except for the non-cirrhosis group (P > 0.05). The differences in proportion with LPR larger than 1.462 between 10-min HBP and adequate HBP were not statistically significant in all groups (all P > 0.05). CONCLUSION: The adequate HBP obtained according to the 2016 ESGAR consensus statement could provide larger LPR and better lesions' conspicuity than 10- min HBP, especially for cirrhotic patients; however, the efficacy of using an LPR cutoff of 1.462 as the standard of the adequate HBP may be compromised in patients with cirrhosis.

Clinicopathological features and surgical treatments of intraductal papillary neoplasm of the bile duct: a case report and literature review.

Intraductal papillary neoplasm of bile duct (IPNB), as a precancerous lesion of cholangiocarcinoma, is a rare biliary tract tumor. A 66-year-old female patient was found to have a bile duct mass by routine examination. The liver function tests and tumor markers were normal. Imaging findings revealed a 2.6 cm mass in the common hepatic duct, accompanied by dilatation of both intrahepatic and extrahepatic bile ducts. The patient underwent open extrahepatic bile duct resection, cholecystectomy and Roux-en-Y hepaticojejunostomy. We also conducted a literature review to summarize the clinicopathological features and surgical treatments of IPNB.

Endoscopic sphincterotomy to prevent post-ERCP pancreatitis after self-expandable metal stent placement for distal malignant biliary obstruction (SPHINX): a multicentre, randomised controlled trial.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) with fully covered self-expandable metal stent (FCSEMS) placement is the preferred approach for biliary drainage in patients with suspected distal malignant biliary obstruction (MBO). However, FCSEMS placement is associated with a high risk of post-ERCP pancreatitis (PEP). Endoscopic sphincterotomy prior to FCSEMS placement may reduce PEP risk. OBJECTIVE: To compare endoscopic sphincterotomy to no sphincterotomy prior to FCSEMS placement. DESIGN: This multicentre, randomised, superiority trial was conducted in 17 hospitals and included patients with suspected distal MBO. Patients were randomised during ERCP to receive either endoscopic sphincterotomy (sphincterotomy group) or no sphincterotomy (control group) prior to FCSEMS placement. The primary outcome was PEP within 30 days. Secondary outcomes included procedure-related complications and 30-day mortality. An interim analysis was performed after 50% of patients (n=259) had completed follow-up. RESULTS: Between May 2016 and June 2023, 297 patients were included in the intention-to-treat analysis, with 156 in the sphincterotomy group and 141 in the control group. After the interim analysis, the study was terminated prematurely due to futility. PEP did not differ between groups, occurring in 26 patients (17%) in the sphincterotomy group compared with 30 patients (21%) in the control group (relative risk 0.78, 95% CI 0.49 to 1.26, p=0.37). There were no significant differences in bleeding, perforation, cholangitis, cholecystitis or 30-day mortality. CONCLUSION: This trial found that endoscopic sphincterotomy was not superior to no sphincterotomy in reducing PEP in patients with distal MBO. Therefore, there was insufficient evidence to recommend routine endoscopic sphincterotomy prior to FCEMS placement. TRIAL REGISTRATION NUMBER: NL5130.

Systemic messenger RNA replacement therapy is effective in a novel clinically relevant model of acute intermittent porphyria developed in non-human primates.

OBJECTIVE: Acute intermittent porphyria (AIP) is a rare metabolic disorder caused by haploinsufficiency of hepatic porphobilinogen deaminase (PBGD), the third enzyme of the heme biosynthesis. Individuals with AIP experience neurovisceral attacks closely associated with hepatic overproduction of potentially neurotoxic heme precursors. DESIGN: We replicated AIP in non-human primates (NHPs) through selective knockdown of the hepatic PBGD gene and evaluated the safety and therapeutic efficacy of human PBGD (hPBGD) mRNA rescue. RESULTS: Intrahepatic administration of a recombinant adeno-associated viral vector containing short hairpin RNA against endogenous PBGD mRNA resulted in sustained PBGD activity inhibition in liver tissue for up to 7 months postinjection. The administration of porphyrinogenic drugs to NHPs induced hepatic heme synthesis, elevated urinary porphyrin precursors and reproduced acute attack symptoms in patients with AIP, including pain, motor disturbances and increased brain GABAergic activity. The model also recapitulated functional anomalies associated with AIP, such as reduced brain perfusion and cerebral glucose uptake, disturbances in hepatic TCA cycle, one-carbon metabolism, drug biotransformation, lipidomic profile and abnormal mitochondrial respiratory chain activity. Additionally, repeated systemic administrations of hPBGD mRNA in this AIP NHP model restored hepatic PBGD levels and activity, providing successful protection against acute attacks, metabolic changes in the liver and CNS disturbances. This approach demonstrated better efficacy than the current standards of care for AIP. CONCLUSION: This novel model significantly expands our understanding of AIP at the molecular, biochemical and clinical levels and confirms the safety and translatability of multiple systemic administration of hPBGD mRNA as a potential aetiological AIP treatment.

Successful Use of Fecal Microbiota Transplantation in Management of Nonobstructive Recurrent Cholangitis Following Total Pancreatectomy and Islet Autotransplant.

Alterations in the gut microbiome have been implicated in various pathologies. Fecal microbiota transplantation (FMT) has been offered as a novel treatment for conditions implicated in the disruption of the gut-microbiota axis. This case report details the successful treatment of recurrent nonobstructive cholangitis following a single FMT application in a patient who had previously undergone a hepatobiliary tract surgical diversion. Cholangitis was suspected secondary to reflux of an altered microbiome into the surgically reanastomosed biliary tract, and FMT was justified based on the history of recurrent Clostridioides difficile infections. This case supports the further evaluation of the utility of FMT as one potential treatment of post hepatobiliary surgical diversion cholangitis.

Transduodenal resection of a large papillary tumor by means of intraoperative cholangioscopy.

INTRODUCTION: Papillary adenomas are very rare benign tumors of the gastrointestinal tract. If manageable, purely endoscopic resection is favored. As an alternative, surgical resection via ampullectomy or pancreaticoduodenectomy can be performed. Often, the depth of infiltration cannot be assessed with sufficient precision, leading to pancreaticoduodenectomy for safety reasons. CASE PRESENTATION: We present the case of a 77-year-old patient in whom a transduodenal papillary resection of a large papillary adenoma was performed, after two unsuccessful endoscopic attempts. Intraoperatively, a 3 cm large papillary adenoma was identified in the duodenum. The infiltration depth into the Vater's papilla was evaluated through intraoperative cholangioscopy. Due to the shallow depth of invasion, we strived for a papillary resection under endoscopic guidance, allowing complete tumor removal. The postoperative course was uneventful, and the patient was discharged on postoperative day 14. CLINICAL DISCUSSION: The decision between ampullectomy and pancreaticoduodenectomy is an intraoperative challenge. Intraoperative cholangioscopy demonstrated its potential to aid this decision-making process in this case. Larger-scale studies are needed to establish its clinical value. CONCLUSION: Intraoperative cholangiography can help surgeons assess the depth of infiltration of large papillary adenomas, leading to more precise surgical decisions about the necessary extent of resection.

Real-time ultrasound AR 3D visualization toward better topological structure perception for hepatobiliary surgery.

PURPOSE: Ultrasound serves as a crucial intraoperative imaging tool for hepatobiliary surgeons, enabling the identification of complex anatomical structures like blood vessels, bile ducts, and lesions. However, the reliance on manual mental reconstruction of 3D topologies from 2D ultrasound images presents significant challenges, leading to a pressing need for tools to assist surgeons with real-time identification of 3D topological anatomy. METHODS: We propose a real-time ultrasound AR 3D visualization method for intraoperative 2D ultrasound imaging. Our system leverages backward alpha blending to integrate multi-planar ultrasound data effectively. To ensure continuity between 2D ultrasound planes, we employ spatial smoothing techniques to interpolate the widely spaced ultrasound planes. A dynamic 3D transfer function is also developed to enhance spatial representation through color differentiation. RESULTS: Comparative experiments involving our AR visualization of 3D ultrasound, alongside AR visualization of 2D ultrasound and 2D visualization of 3D ultrasound, demonstrated that the proposed method significantly reduced operational time(110.25 ± 27.83 s compared to 292 ± 146.63 s and 365.25 ± 131.62 s), improved depth perception and comprehension of complex topologies, contributing to reduced pressure and increased personal satisfaction among users. CONCLUSION: Quantitative experimental results and feedback from both novice and experienced physicians highlight our system's exceptional ability to enhance the understanding of complex topological anatomy. This improvement is crucial for accurate ultrasound diagnosis and informed surgical decision-making, underscoring the system's clinical applicability.

To compress or to breath-hold? A systematic review of the impact of motion mitigation techniques on motion, interfraction set-up errors, and intrafraction errors in patients with hepatobiliary and pancreatic malignancies.

BACKGROUND AND PURPOSE: Reducing motion is vital in treating hepatobiliary (HPB) and pancreatic malignancies. Abdominal compression (AC) and breath-hold (BH) techniques aim to minimise respiratory motion, yet their adoption remains limited, and practices vary. This review examines the impact of AC and BH on motion, set-up errors, and patient tolerability in HPB and pancreatic patients. MATERIALS AND METHODS: This systematic review, conducted using PRISMA and PICOS criteria, includes publications from January 2015 to February 2023. Eligible studies focused on AC and BH interventions in adults with HPB and pancreatic malignancies. Endpoints examined motion, set-up errors, intra-fraction errors, and patient tolerability. Due to study heterogeneity, Synthesis Without Meta-Analysis was used, and a 5 mm threshold assessed the impact of motion mitigation. RESULTS: In forty studies, 14 explored AC and 26 BH, with 20 on HPB, 13 on pancreatic, and 7 on mixed cohorts. Six studied pre-treatment, 22 inter/intra-fraction errors, and 12 both. Six AC pre-treatment studies showed > 5 mm motion, and 4 BH and 2 AC studies reported > 5 mm inter-fraction errors. Compression studies commonly investigated the arch and belt, and DIBH was the predominant BH technique. No studies compared AC and BH. There was variation in the techniques, and several studies did not follow standardised error reporting. Patient experience and tolerability were under-reported. CONCLUSION: The results indicate that AC effectively reduces motion, but its effectiveness may vary. BH can immobilise motion; however, it can be inconsistent between fractions. The review underscores the need for larger, standardised studies and emphasizes the importance of considering the patient's perspective for tailored treatments.

Predictive Factors of Canine Malignant Hepatic Diseases with Multifocal Hepatic Lesions Using Clinicopathology, Ultrasonography, and Hepatobiliary Ultrasound Scores.

Multifocal hepatic lesions in dogs arise from various benign and malignant liver diseases. Diagnosing these lesions is challenging because clinical signs, hematological data, and serum biochemistry are not definitive indicators. Ultrasound is utilized as a diagnostic imaging tool to evaluate liver parenchyma and detect hepatic lesions. This study aims to investigate the predictive factors that differentiate between benign and malignant multifocal hepatic lesions by examining ultrasound characteristics, blood tests, and serum biochemistry. In total, 43 dogs with multifocal hepatic lesions were included in this study. All dogs were classified into benign hepatic diseases (n = 32) and malignant haptic diseases (n = 11). For all dogs, their liver characteristics, lesion characteristics, and hepatobiliary ultrasound score by ultrasound were evaluated and we collected individual clinicopathological data for analysis. The findings of the univariate analysis revealed significant differences in four hematological and blood chemical parameters (hematocrit, white blood cell count, aspartate transaminase (AST), and alkaline phosphatase (ALP)) and six ultrasonographic parameters (liver parenchymal echogenicity, lesion homogeneity, lesion echogenicity, maximum lesion dimension, average lesion dimension, and hepatobiliary ultrasound score). Using multivariate analysis, only two parameters, hepatobiliary ultrasound score and lesion homogeneity, showed significant differences (p-value < 0.001 and p-value = 0.011, respectively). Additionally, these parameters demonstrated high accuracy in predicting malignant multifocal liver lesions, with accuracy rates of 97.67% and 93.02%, respectively. Therefore, the hepatobiliary ultrasound score and lesion homogeneity are considered effective parameters for screening malignant multifocal liver lesions in dogs.

Prospective cohort for early detection of liver cancer (Pearl): a study protocol.

INTRODUCTION: Hepatocellular carcinoma (HCC) is the fastest-rising and fourth most common cause of cancer death worldwide. Liver cirrhosis is the largest underlying risk factor for HCC. Therefore, patients with cirrhosis should have regular ultrasound and biochemical screening to pick up early HCC. Early HCC can be cured; more advanced HCCs have limited treatment options and poor prognosis. Current screening methods are suboptimal with poor sensitivity in picking up early disease. In this study, the investigators aim to recruit people with liver cirrhosis into a Prospective cohort for early detection of liver cancer-the Pearl cohort. The investigators believe that by using state-of-the-art tests we can improve the detection of early HCC. METHODS AND ANALYSIS: This is a UK-based prospective, longitudinal, diagnostic, prognostic, multicentre, non-CTIMP study. Aiming to recruit 3000 patients with liver cirrhosis without a HCC diagnosis, the Pearl cohort will be followed actively for 3 years from recruitment and then passively via registry data for ten years thereafter. Blood and urine samples will be taken and information from routine care will be gathered. These will be used to assess novel diagnostic approaches for the detection early HCC and to develop models to identify those most at risk for developing HCC.Participants will be linked to national UK health registries to ensure long-term capture of HCC incidence and other relevant endpoints. Approximately 75 patients are predicted to develop de novo HCC within the 3-year follow up period. After this period, the study teams will obtain data on participants for at least 10 years after the last contact. This cohort will help develop an understanding of the incidence of HCC in a UK population stratified by underlying cirrhosis aetiology. ETHICS AND DISSEMINATION: Ethical approval has been granted by REC and the trial is registered on ClinicalTrials.gov. The results will be published in peer-reviewed journals and presented at relevant meetings. TRIAL REGISTRATION NUMBER: NCT05541601.

[Anastomotic leakage in hepato-pancreato-biliary surgery]. / Anastomoseninsuffizienzen in der hepatopankreatobiliären Chirurgie.

Severe complications following hepato-pancreato-biliary surgery are frequently due to leakage of anastomoses. Local intraoperative and systematic measures can reduce the incidence of leaks and leak-related sequelae. The early identification of leak-related sequelae, such as hemorrhage is pivotal to reduce the mortality risk. Therefore, perioperative risk stratification incorporating surgical and patient risk factors is crucial. The management of anastomotic leaks is complex and an interdisciplinary treatment is therefore recommended. The treatment depends on the institutional expertise, localization, characteristic features of the anastomosis and the onset of insufficiency. This article describes the different concepts of the diagnostics, prevention, consequences and management of anastomotic leakage in hepato-pancreato-biliary surgery in more detail.

Essential Elements in Synoptic Operative Reports for Hepato-Pancreato-Biliary Cancer Surgery: An HPB/CGSO Training Program Survey.

BACKGROUND: Synoptic operative reports (SORs) are checklists or templates that contain standardized elements of an operation. These elements are associated with standardized inclusion of critical elements of the operative report that translate into numerous potential benefits. Whereas SORs for melanoma, breast, and colorectal cancer surgery have already been widely implemented, similar templates for hepato-pancreato-biliary (HPB) cancer surgery are currently lacking. METHODS: An anonymous voluntary online survey was distributed to HPB attendings and fellows at HPB and complex general surgical oncology (CGSO) fellowship programs. RESULTS: The 54 participants in this study comprised 31 (57%) HPB surgery attendings, 15 (28%) HPB surgery fellows, and 8 (15%) CGSO fellows. Notably, only six (11%) participants reported consistent use of an HPB SOR. The most commonly reported barriers to SOR uptake were the "lack of a readily available template" (55%) and the "lack of consensus/guidelines" (49%). Despite these limiting factors, a majority of respondents indicated a strong willingness to use a standardized and readily available HPB SOR (mean, 4.13/5 ± 1.23). This interest did not differ between attendings and fellows (p = 0.52) or between the participants stratified by surgical experience (p = 0.58). Finally, the participants were provided a comprehensive list of possible elements to incorporate into a standardized pancreatic and hepatobiliary SOR. After the exclusion of elements with less than 75% agreement, the pancreatic SORs included 17 (57%) of 30 possible elements, and the hepatobiliary SORs included 19 (76%) of 25 possible elements. CONCLUSION: Broad consensus on several elements of the HPB SOR suggests that uptake should be accelerated in HPB surgery.

Feasibility, safety and preliminary efficacy of preoperative stereotactic radiotherapy on the future pancreatic neck transection margin to reduce the risk of pancreatic fistula after high-risk pancreatoduodenectomy (FIBROPANC): protocol for a multicentre, single-arm trial.

INTRODUCTION: Postoperative pancreatic fistula (POPF) occurs in 25% of patients undergoing a high-risk pancreatoduodenectomy (PD) and is a driving cause of major morbidity, mortality, prolonged hospital stay and increased costs after PD. There is a need for perioperative methods to decrease these risks. In recent studies, preoperative chemoradiotherapy in patients with pancreatic ductal adenocarcinoma (PDAC) reduced the rate of POPF seemingly due to radiation-induced pancreatic fibrosis. However, patients with a high risk of POPF mostly have a non-pancreatic periampullary tumour and do not receive radiotherapy. Prospective studies using radiotherapy specifically to reduce the risk of POPF have not been performed. We aim to assess the safety, feasibility and preliminary efficacy of preoperative stereotactic radiotherapy on the future pancreatic neck transection margin to reduce the rate of POPF. METHODS AND ANALYSIS: In this multicentre, single-arm, phase II trial, we aim to assess the feasibility and safety of a single fraction of preoperative stereotactic radiotherapy (12 Gy) to a 4 cm area around the future pancreatic neck transection margin in patients at high risk of developing POPF after PD aimed to reduce the risk of grade B/C POPF. Adult patients scheduled for PD for malignant and premalignant periampullary tumours, excluding PDAC, with a pancreatic duct diameter ≤3 mm will be included in centres participating in the Dutch Pancreatic Cancer Group. The primary outcome is the safety and feasibility of single-dose preoperative stereotactic radiotherapy before PD. The most relevant secondary outcomes are grade B/C POPF and the difference in the extent of fibrosis between the radiated and non-radiated (uncinate margin) pancreas. Evaluation of endpoints will be performed after inclusion of 33 eligible patients. ETHICS AND DISSEMINATION: Ethical approval was obtained by the Amsterdam UMC's accredited Medical Research Ethics Committee (METC). All included patients are required to have provided written informed consent. The results of this trial will be used to determine the need for a randomised controlled phase III trial and submitted to a high-impact peer-reviewed medical journal regardless of the study outcome. TRIAL REGISTRATION NUMBER: NL72913 (Central Committee on Research involving Human Subjects Registry) and NCT05641233 (ClinicalTrials).

Psychotropic medication and hepatobiliary health: Ultrasound observations on patients with schizophrenia.

OBJECTIVE: This study sought to examine the association between antipsychotic drug use and hepatobiliary health based on serum markers and ultrasound observations on a sample of patients with schizophrenia compared to age and gender matched healthy controls. METHODS: The 120 patients with schizophrenia and 60 control subjects had their blood drawn to measure liver function tests and underwent hepatobiliary ultrasonography to determine hepatobiliary lesions. Liver function tests included total cholesterol (TC), triglycerides (TG), alanine aminotransferase (ALT), and aspartate aminotransferase (AST). Standardized cross-sectional images of the liver and kidneys were obtained from patients and controls, and analyses were stratified by length of taking psychotropic medication among those with schizophrenia. Liver echo attenuation coefficients, liver-kidney ratios, and liver fat content were determined. RESULTS: Psychotropic drug use was associated with greater liver burden and liver lesions in patients with schizophrenia compared to controls. The levels of TC, TG, ALT and AST in patients with schizophrenia were also all significantly higher among patients with schizophrenia. Long-term psychotropic medication was associated with increased levels of fatty liver in patients compared with controls. Levels of TC, TG, ALT and AST were all significantly higher in the long-term psychotropic medication use group than in the short-term group. Liver echo attenuation coefficient, liver-kidney ratio, and liver fat content were also higher in the long-term medication use group compared to the short-term group. CONCLUSION: Antipsychotic drug use, particularly long-term use, is associated with increased liver burden in patients with schizophrenia, impaired lipid metabolism, increased liver lesions and fat content.

Randomized, controlled, multi-center phase II study of postoperative enoxaparin treatment for venous thromboembolism prophylaxis in patients undergoing surgery for hepatobiliary-pancreatic malignancies.

Purpose: Postoperative venous thromboembolism (VTE) risk is pronounced after abdominal cancer surgery. Enoxaparin shows promise in preventing VTE in gastrointestinal, gynecological, and urological cancers, but its application after surgery for hepatobiliary-pancreatic malignancy has been under-evaluated due to bleeding concerns. We confirmed the safety of enoxaparin administration in patients undergoing curative hepatobiliary-pancreatic surgery for malignancies in a prospective, multi-center, phase I study. Methods: The study was conducted from April 2015 to May 2021 across eight specialized centers. Patients (n = 262) were randomized to enoxaparin prophylaxis given postoperatively for 8 days (n = 131) or control (n = 131). The primary endpoint was the efficacy in reducing VTE. Secondary endpoints examined safety. Results: The full analysis set included 259 patients (131 control, 129 enoxaparin). The per-protocol population included 233 patients (117 control, 116 enoxaparin). Most cases were hepatic malignancies (111 control, 111 enoxaparin). The median administration duration of enoxaparin was 7 days, with 92% receiving 4000 units/day. Despite a reduction in the relative risk (RR) of VTE due to postoperative enoxaparin administration, the results were not significant (control: four cases, 3.4% vs. treatment: two cases, 1.7%; RR 0.50, 95% CI 0.09-2.70; p = 0.6834). No significant difference was found in the incidence of bleeding events (control: five cases, 4.3% vs. treatment: five cases, 4.3%, RR 1.00, 95% CI 0.53-1.89; p = 1.0000). Conclusions: The perioperative administration of enoxaparin in hepatobiliary-pancreatic malignancies is feasible and safe. However, further case accumulation and investigation are necessary to assess its potential in reducing the occurrence of VTE.

Intracholecystic Papillary Neoplasm: A Case Report.

We present a case of a 30-year-old female with symptomatic gallstones and associated gallbladder polyps. An incidental finding of intracholecystic papillary neoplasm (ICPN) with high-grade dysplasia was found after pathological examination of the gallbladder after robotic cholecystectomy. This rare condition can be associated with malignant transformation. In this case report, we discuss this rare entity and share our experience and review of the literature.

PET/MRI: pictorial review of hepatobiliary and pancreatic applications.

PET and MRI both play valuable roles in the management of hepatobiliary and pancreatic (HBP) malignancies. Simultaneous PET/MRI combines the excellent soft-tissue resolution and anatomic details from MRI with functional information from PET in a single comprehensive examination. MRI is the main imaging modality in evaluating HCC, playing important roles in screening, characterization, local extent, and evaluating tumor response, whereas 18F-fluorodeoxyglucose (FDG) PET can help evaluate for lymph node involvement and metastatic disease. In cholangiocarcinoma and pancreatic malignancies, both PET and MRI have excellent utility in initial staging as well as assessing treatment response. In all HBP malignancies, FDG-PET/MRI is a unique problem-solving tool in complex cases and diagnostic challenges, especially after locoregional therapy and when differentiating residual or recurrent viable disease from inflammatory and other benign processes. In this manuscript, we review the role of PET/MRI in the diagnosis, staging, assessing treatment response, and characterizing post-treatment processes. With the introduction of multiple new tracers, the value of PET/MRI has not yet been fully realized, and more studies are needed to demonstrate the utility and efficacy of PET/MRI in improving patient care in hepatobiliary and pancreatic oncology.

Hepatobiliary complications of immune checkpoint inhibitors in cancer.

Immune checkpoint inhibitors (ICIs) have dramatically changed the landscape of cancer therapy. Over the last decade, both their primary focus in trials and clinical application have exponentially risen, with repeated demonstrations of their efficacy in improving survival in various cancer types. The adverse effects of these drugs on various organ systems were recognised in early phase studies. Given their relatively new emergence on the market, there has been increasing interest into short- and long-term effects and management of ICIs in real-world settings. ICI-related hepatobiliary toxicities are often challenging to diagnose and difficult to distinguish from other causes of deranged liver biochemical tests. The aim of this review is to provide an up-to-date and detailed exploration of the hepatobiliary complications of ICIs, including pathogenesis and approaches to diagnosis and management.