Andrea Laurenzi

Defining Benchmarks for Major Liver Surgery: A multicenter Analysis of 5202 Living Liver Donors.

Objective: To measure and define the best achievable outcome after major hepatectomy. Background: No reference values are available on outcomes after major hepatectomies. Analysis in living liver donors, with safety as the highest priority, offers the opportunity to define outcome benchmarks as the best possible results. Methods: Outcome analyses of 5202 hemi-hepatectomies from living donors (LDs) from 12 high-volume centers worldwide were performed for a 10-year period. Endpoints, calculated at discharge, 3 and 6 months postoperatively, included postoperative morbidity measured by the Clavien-Dindo classification, the Comprehensive Complication Index (CCI), and liver failure according to different definitions. Benchmark values were defined as the 75th percentile of median morbidity values to represent the best achievable results at 3 month postoperatively. Results: Patients were young (34 ± [9] years), predominantly male (65%) and healthy. Surgery lasted 7 ± [2] hours; 2% needed blood transfusions. Mean hospital stay was 11.7± [5] days. 12% of patients developed at least 1 complication, of which 3.8% were major events (≥grade III, including 1 death), mostly related to biliary/bleeding events, and were twice higher after right hepatectomy. The incidence of postoperative liver failure was low. Within 3-month follow-up, benchmark values for overall complication were ⩽31 %, for minor/major complications ⩽23% and ⩽9%, respectively, and a CCI ⩽33 in LDs with complications. Centers having performed ≥100 hepatectomies had significantly lower rates for overall (10.2% vs 35.9%, P < 0.001) and major (3% vs 12.1%, P < 0.001) complications and overall CCI (2.1 vs 8.5, P < 0.001). Conclusions: The thorough outcome analysis of healthy LDs may serve as a reference for evaluating surgical performance in patients undergoing major liver resection across centers and different patient populations. Further benchmark studies are needed to develop risk-adjusted comparisons of surgical outcomes.

Defining Benchmarks for Major Liver Surgery

Fabian Rössler, MD, Gonzalo Sapisochin, MD,y GiWon Song, MD,z Yu-Hung Lin, MD,§ Mary Ann Simpson, MD, PhD, Kiyoshi Hasegawa, MD, PhD,jj Andrea Laurenzi, MD, Santiago Sánchez Cabús, MD, PhD,yy Milton Inostroza Nunez, MD,zz Andrea Gatti, MD,§§ Magali Chahdi Beltrame, MD, Ksenija Slankamenac, MD, PhD, Paul D. Greig, MD,y Sung-Gyu Lee, MD, PhD,z Chao-Long Chen, MD, PhD,§ David R. Grant, MD,y Elizabeth A. Pomfret, MD, PhD, Norihiro Kokudo, MD, PhD,jj Daniel Cherqui, MD, Kim M. Olthoff, MD,jjjj Abraham Shaked, MD,jjjj Juan Carlos Garcı́a-Valdecasas, MD, PhD,yy Jan Lerut, MD, PhD,zz Roberto I. Troisi, MD, PhD,§§ Martin De Santibanes, MD, Henrik Petrowsky, MD, Milo A. Puhan, MD, PhD, and Pierre-Alain Clavien, MD, PhD

Laparoscopic Pancreaticoduodenectomy: Right Posterior Superior Mesenteric Artery “First” Approach

AbstractPancreaticoduodenectomy (PD) is considered one of the most challenging abdominal operations for several reasons, including the anatomy, which is surrounded by vital vascular structures and also because of the serious complications that are possible in the postoperative period. Nowadays, thanks to the development of minimally invasive surgery and improvement of patients’ selection, laparoscopic pancreatic resections have been proven to be technically feasible and safe especially in the case of left pancreatectomies. More recently, many series of laparoscopic PD for adenocarcinoma have been published demonstrating the feasibility of this technique. In pancreatic cancer, the advantage of superior mesenteric artery “first approach” is already known to achieve an oncological resection. The purpose of this video is to describe the different technical aspects of the laparoscopic superior mesenteric artery first approach in the right posterior fashion.

Repeat liver retransplantation: rationale and outcomes.

Liver retransplantation remains the only option for recurrent graft failure. The aim of our study is to identify predictive factors involved in patients and graft survival for patients undergoing repeat retransplantation (RRT).

Open Liver Resection, Laparoscopic Liver Resection, and Percutaneous Thermal Ablation for Patients with Solitary Small Hepatocellular Carcinoma (≤30 mm): Review of the Literature and Proposal for a Therapeutic Strategy

Background: Patients with a single hepatocellular carcinoma (HCC) ≤3 cm and preserved liver function have the highest likelihood to be cured if treated. The most adequate treatment methods are yet a matter that is debated. Methods: We reviewed the literature about open anatomic resection (AR), laparoscopic liver resection (LLR), and percutaneous thermal ablation (PTA). Results: PTA is effective as resection for HCC < 2 cm, when they are neither subcapsular nor perivascular. PTA in HCC of 2–3 cm is under evaluation. AR with the removal of the tumor-bearing portal territory is recommended for HCC > 2 cm, except for subcapsular ones. In comparison with open surgery, LRR has better short-term outcomes and non-inferior long-term outcomes. LLR is standardized for superficial limited resections and for left-sided AR. Conclusions: According to the available evidences, the following therapeutic proposal can be advanced. Laparoscopic limited resection is the standard for any subcapsular HCC. PTA is the first-line treatment for deep-located HCC < 2 cm, except for those in contact with Glissonean pedicles. Laparoscopic AR is the standard for deep-located HCC of 2–3 cm of the left liver, while open AR is the standard for deep-located HCC of 2–3 cm in the right liver. HCC in contact with Glissonean pedicles should be scheduled for resection (open or laparoscopic) independent of their size. Liver transplantation is reserved to otherwise untreatable patients or as a salvage procedure at recurrence.

Laparoscopic Distal Pancreatectomy

Laparoscopic distal pancreatectomy (LDP) was firstly described by Gagner in 1996 [1]. Nevertheless 20 years have passed from the first resection, the rate of laparoscopic approach remains between 10–20% in national wide series [2–4]. Recently a Cochrane review has compared the open to the laparoscopic approach in the treatment of pancreatic cancer [5]. In such review there are no differences between the two groups in terms of post-operative mortality, morbidity, pancreatic fistula, resection margins and disease recurrence. The only statistically significant difference is the length of hospital stay, which is in favor of laparoscopic approach. Currently there is an ongoing randomized clinical trial comparing the open versus laparoscopic distal pancreatectomy (Leopard NTR 5188).

What is the impact of neoadjuvant chemoradiation on outcomes in gastro-intestinal cancer?

Multimodal therapeutic strategies combining chemotherapy, radiation therapy and surgery have been shown to be feasible and to have a positive impact on outcomes by decreasing the risk of locoregional recurrence and often by increasing overall survival. The advantages of neoadjuvant chemo(radio)therapy include optimal tumor control combined with better tolerance and compliance to treatment while also increasing the number of candidates for surgery. Whereas indications for neoadjuvant therapy are increasing, its impact on surgical treatment and postoperative outcomes are not well-known. Surgeons frequently believe that chemo(radio)therapy may amplify intraoperative difficulties, thereby increasing postoperative morbidity and mortality. The aim of this review was to report the state of the art regarding: (i) the role of chemo(radio)therapy; (ii) its impact on surgical indications and modalities; and (iii) its impact on postoperative outcomes for the most frequently encountered gastro-intestinal cancers, i.e. esophageal, rectal, pancreatic, and anal canal cancer.