Guido Fiorentini

Minimally invasive approach to intrahepatic cholangiocarcinoma: technical notes for a safe hepatectomy and lymphadenectomy

Background: Despite the improvements of laparoscopic (LPS) technologies and their extensive application to the treatment of liver diseases, minimally invasive approach to intrahepatic cholangiocarcinoma (ICC) is still poorly widespread. The aim of the present study is to investigate the extension and the diffusion of laparoscopy applied to surgical treatment of ICC. n Methods: We reviewed studies dealing with the LPS treatment of ICC and LPS lymphadenectomy (LND) for ICC. Data regarding conversion rate, morbidity and LND were extracted, synthesized and analyzed. Additionally, we described technical notes for a safe liver resection and LND. n Results: We identified 11 studies encompassing liver resections for ICCs. Among a total of 1,882 cases included, there were 101 (5.5%) patients treated laparoscopically who were affected by ICC. The observed conversion rate was comparable to that of other LPS advanced procedures; laparoscopy was not responsible for increased morbidity and LND was demonstrated being feasible without causing any increasing in the post-operative complications. Furthermore, no differences in disease free survival and on the 3-year overall survival were observed. n Conclusions: Few are the cases of ICC that are nowadays tackled laparoscopically. Hepatic resection and LPS LND for ICC are feasible and safe; as more, laparoscopy granted both short and long term results that were comparable to open surgery, extending the applicability of minimally invasive surgery.

Laparoscopic left hepatectomy for mucinous cystic neoplasm of the liver

BackgroundAmong liver cystic lesions, mucinous cystic neoplasm of the liver (MCN-L) constitutes a challenging issue in terms of management: preoperative diagnosis is often unachievable and this may mislead to inappropriate treatment [1–3]. We present the case of an otherwise healthy 29-year-old female who underwent laparotomic cyst unroofing in segment 4 and cholecystectomy in another institution. Post-operative course was complicated by biliary leakage that was endoscopically treated. Short term follow-up showed early recurrence with a volumetric enlargement of the cyst occupying most of the left hepatic lobe and new satellite cyst in Sg5. The doubt of MCN-L arose, and the patient was scheduled for laparoscopic removal at our Centre, despite the previous laparotomic procedure.MethodsAn optic port was placed into right upper abdominal quadrant and 3 further ports were placed. A long and difficult adhesiolysis was performed and Pringle’s manoeuver was settled. Intraoperative US confirmed the anatomic limits of the cysts in Sg5 and in the left hepatic lobe. The cyst on Sg5 was resected first and frozen section was suspicious for MCN-L. In order to prevent recurrence, left laparoscopic hepatectomy was performed. The specimen was extracted through the previous midline laparotomy.ResultsPost-operative course was uneventful and the patient was discharged on POD 5. Pathology and immunochemistry confirmed the diagnosis of MCN-L.ConclusionHepatic cystic lesions may be insidious and preoperative biopsy is not always possible due to lack of solid tissue. In unclear settings, an intraoperative frozen section is mandatory to guide intraoperative decisions. In the suspicion of malignancy, resection with oncologic criteria must be chosen as the most appropriate treatment, as well as the retrieving of MCN-L requires hepatic resection to avoid early recurrence [4, 5]. Despite of previous laparotomy, we consider a laparoscopic approach could be attempted in selected cases, in institution with particular expertise in laparoscopic liver surgery.

Effect of Previous Abdominal Surgery on Laparoscopic Liver Resection: Analysis of Feasibility and Risk Factors for Conversion

INTRODUCTIONnPrevious abdominal surgery has traditionally been considered an additional element of difficulty to later laparoscopic procedures. The aim of the study is to analyze the effect of previous surgery on the feasibility and safety of laparoscopic liver resection (LLR), and its role as a risk factor for conversion.nnnMATERIALS AND METHODSnAfter matching, 349 LLR in patients known for previous abdominal surgery (PS group) were compared with 349 LLR on patients with a virgin abdomen (NPS group). Subgroup analysis included 161 patients with previous upper abdominal surgery (UPS subgroup). Feasibility and safety were evaluated in terms of conversion rate, reasons for conversion and outcomes, and risk factors for conversion assessed via uni/multivariable analysis.nnnRESULTSnConversion rate was 9.4%, and higher for PS patients compared with NPS patients (13.7% versus 5.1%, Pu2009=u2009.021). Difficult adhesiolysis resulted the commonest reason for conversion in PS group (5.7%). However, operative time (Pu2009=u2009.840), blood loss (Pu2009=u2009.270), transfusion (Pu2009=u2009.650), morbidity rate (Pu2009=u2009.578), hospital stay (Pu2009=u2009.780), and R1 rate (Pu2009=u2009.130) were comparable between PS and NPS group. Subgroup analysis confirmed higher conversion rates for UPS patients (23%) compared with both NPS (Pu2009=u2009.015) and PS patients (Pu2009=u2009.041). Previous surgery emerged as independent risk factor for conversion (Pu2009=u2009.033), alongside the postero-superior location and major hepatectomy.nnnCONCLUSIONnLLR are feasible in case of previous surgery and proved to be safe and maintain the benefits of LLR carried out in standard settings. However, a history of surgery should be considered a risk factor for conversion.

Laparoscopic vs Open Surgery for Colorectal Liver Metastases

Importance Surgery represents the mainstay treatment of colorectal liver metastases. Indications for the laparoscopic approach in this setting have been widened and there is a need to confirm the benefits of minimally invasive liver surgery (MILS) in patients with complex disease states. Objective To compare outcomes of laparoscopic surgery with those of open surgery for liver metastases from colorectal cancer, focusing on the characteristics of modern MILS and therefore overcoming possible selection bias related to different policies for patients’ eligibility for MILS over time. Design, Setting, and Participants A cohort study of 885 resections performed for liver metastases from colorectal cancer between January 1, 2004, and June 30, 2017, at the Hepatobiliary Surgery Unit of San Raffaele Hospital, Milano, Italy, comprising 187 laparoscopic and 698 open resections. Procedures performed using the MILS approach with a ratio of MILS to total resections per year of more than 30% were considered and were matched by propensity scores (ratio of 1:4) to procedures performed using the open approach with a ratio of MILS to total resections per year of less than 30%. Main Outcomes and Measures The primary end point was short-term outcomes, including morbidity, mortality, functional recovery, and interval between surgery and adjuvant treatments; the secondary end point was long-term outcomes. Results Among this cohort (104 patients in the MILS group; 46 women and 58 men; median age, 62 years [range, 35-81 years]; and 412 patients in the open group; 181 women and 231 men; median age, 60 years [range, 37-80 years]), primary end-point data showed a significantly higher incidence of postoperative morbidity in patients who underwent open resections compared with those who underwent MILS (94 [22.8%] vs 21 [20.2%]; Pu2009=u2009.04). Patients in the MILS group had fewer major complications (Dindo-Clavien grades III-V) compared with patients in the open group (Dindo-Clavien grades III-V; 7 [6.7%] vs 35 [8.5%]; Pu2009=u2009.03) as well as shorter lengths of stay (median [range] duration, 3 [2-35] vs 5 [4-37] days; Pu2009=u2009.02). Oncologic results were not compromised by the laparoscopic approach. Conclusions and Relevance In this study, the results of the propensity score matching analysis between modern laparoscopic surgery and previous open surgery appear to confer more comparable cohorts for complexity, further supporting the advantages of laparoscopy in the surgical treatment of liver metastases from colorectal cancer. The increase in use that laparoscopy has experienced appears to be based on increased feasibility, widening of eligibility criteria for patients, enhanced clinical effectiveness, and oncologic outcomes. All these elements together suggest that up to 70% of patients appear to be candidates for this minimally invasive surgical approach in high-volume centers.

Safety of minimally invasive liver resections during live surgery: a propensity score based assessment

BACKGROUNDnConcerns regarding safety and outcomes of procedures performed during live events have been raised in the literature. Aim of the present investigation was to analyze the outcomes of laparoscopic liver resections performed during live events and conventional elective procedures.nnnMETHODSn60 laparoscopic liver resections performed during live events (Live group) were compared with 180 performed during conventional elective procedures (Control group) after propensity scores matching. The main endpoints were intraoperative and short-term postoperative outcomes.nnnRESULTSnLive and Control group had comparable blood loss (300 vs 350xa0mL, p NS) and conversion rate (13.3% vs 14.4%, p NS), despite longer operation time for patients in the Live Group (280xa0±xa030 vs 210xa0±xa020xa0min, pxa0=xa00.032). There were no differences in perioperative morbidity and mortality: severe complications respectively occurred in 2 patients of the Live and in 7 patients of the Control group (p NS) with none directly related to intraoperative accidents.nnnCONCLUSIONSnIn the setting of laparoscopic liver resections, live surgery does not negatively affect intra- and postoperative outcomes of patients if performed by expert surgeons: the creation of a specific expertise for the new generations of laparoscopic liver surgeons can be therefore pursued maintaining the primary endpoint of safety and oncological adequacy of procedures.

Management of hilum infiltrating tumors of the liver: The impact of experience and standardization on outcome

BACKGROUNDnThe primary endpoint of this study was to evaluate the outcome of surgery for perihilar cholangiocarcinoma in a high-volume tertiary referral center.nnnMETHODSnThe study population consisted of 196 consecutive patients with histologically confirmed perihilar cholangiocarcinoma-PHC-who were candidates to surgical treatment. Factors affecting postoperative morbidity were evaluated in the whole series (primary endpoint) and after stratification of patients according to the following criteria: (a) perioperative management protocol implementation; (b) monocentric management (secondary endpoint).nnnRESULTSnThe postoperative morbidity rate was 51.5% and mortality 4.1%. The most frequent cause of death was postoperative liver failure. At multivariate analysis, factors affecting the risk of morbidity were: side of hepatectomy, liver volume, intraoperative blood loss, preoperative optimization and single-center management. Patients treated according to preoperative optimization protocol, as well as patients with monocentric management experienced a significant reduction of postoperative morbidity. Preoperative optimization and single-center management significantly affected even long term outcome of patients.nnnCONCLUSIONnDespite continuous improvement in the surgical field, hilum-infiltrating tumors still remain associated with therapeutic and management challenges: a correct preoperative management in a tertiary referral center provides a benefit in terms of morbidity and mortality, thus improving long term results.

Perioperative and Long-Term Outcomes of Laparoscopic Versus Open Lymphadenectomy for Biliary Tumors: A Propensity-Score-Based, Case-Matched Analysis

BackgroundThe purpose of this study was to compare patients undergoing MILS and open liver resections with associated lymphadenectomy for biliary tumors (intrahepatic cholangiocarcinoma and gallbladder cancer) in a case-matched analysis using propensity scores.MethodsA total of 104 consecutive patients underwent liver resection with associated locoregional lymphadenectomy by laparoscopic approach constituted the study group (MILS group). The MILS group was matched in a ratio of 1:2 with patients who had undergone open resection for primary biliary cancers (Open group). Short- and long-term outcomes were evaluated and compared, with specific focus on specific details of lymphadenectomy.ResultsLaparoscopic series resulted in a statistically significant lower blood loss (200 vs. 350, pu2009=u20090.03), minor intraoperative blood transfusions (3.2% vs. 7.9%, pu2009=u20090.04), and postoperative blood transfusions (10.5% vs. 15.8%), other than shorter length of stay (4 vs. 6xa0days, pu2009=u20090.04). Number of retrieved nodes was 8 versus 7 (pu2009=u2009not significant); particularly, percentage of patients who achieved the recommended AJCC cutoff of six lymph nodes harvested were 93.7% versus 85.8% (pu2009=u20090.05). Both overall and lymphadenectomy-related morbidity (bleeding, pancreatitis, lymphatic fistula, vascular, and biliary injuries) were lower in MILS group (respectively 16.3% and 3.2% vs. 22.1% and 5.3%, pu2009=u20090.03). Median disease-free survival was 33 versus 36xa0months and disease recurrence occurred in 45.3% versus 55.3% of patients in MILS and Open groups respectively.ConclusionsLaparoscopic approach for lymphadenectomy is a valid option in patients with biliary cancers, because it allows to maintain the advantages of minimally invasive approach, without compromising the accuracy and the outcomes of nodal dissection.

Tips and Tricks for a Laparoscopic Approach to Paracaval Liver Segments

BackgroundA dramatic spread of laparoscopic liver surgery has been experienced over the last years. The approach to paracaval liver segments 1 and 9 is still poorly described in literature, mainly due to its technical demands.ObjectiveThe aim of this article was to introduce a safe and effective approach to paracaval liver segments through laparoscopy.MethodsA minimally invasive approach to resection of Segments 1 and 9 is presented, and an operative set-up is depicted. A step-by-step technique describing the inferior vena cava (IVC) with left and right hepatic venous junction exposure, segmental pedicle isolation, and parenchymal transection is shown through a video document.ResultsPostoperative courses were uneventful, and patients were discharged on postoperative dayxa03.DiscussionThe approach to paracaval liver segments requires accurate preoperative case selection, technical, surgical, and anesthesiological expertise in laparoscopic liver surgery, and adequate instrumentary.ConclusionParacaval segments of the liver can be approached safely through laparoscopy by teams with extensive expertise in the field of laparoscopic liver surgery; however, suspected malignant infiltration of the IVC or unclear preoperative anatomy still contraindicate this approach.

Nonspecific Abdominal Pain

Five to ten percent of all admissions to the emergency department (ED) are due to acute abdominal pain. Acute nonspecific abdominal pain (NSAP) is defined as acute abdominal pain less than one week in duration, for which there is no diagnosis despite investigations and comprises a spectrum of undiagnosed conditions, both somatic and functional, and remains a “diagnosis of exclusion.”