Publications by authors named "Alessandro Ferrero"

106 Publications

Technical feasibility and short-term outcomes of laparoscopic isolated caudate lobe resection: an IgoMILS (Italian Group of Minimally Invasive Liver Surgery) registry-based study.

Surg Endosc 2021 Mar 31. Epub 2021 Mar 31.

Department of Hepatobiliary Surgery, Unit of Hepato-Pancreato-Biliary Surgery, G. B. Rossi Hospital, University of Verona Medical School, Verona, Italy.

Background: Although isolated caudate lobe (CL) liver resection is not a contraindication for minimally invasive liver surgery (MILS), feasibility and safety of the procedure are still poorly investigated. To address this gap, we evaluate data on the Italian prospective maintained database on laparoscopic liver surgery (IgoMILS) and compare outcomes between MILS and open group.

Methods: Perioperative data of patients with malignancies, as colorectal liver metastases (CRLM), hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC), non-colorectal liver metastases (NCRLM) and benign liver disease, were retrospectively analyzed. A propensity score matching (PSM) analysis was performed to balance the potential selection bias for MILS and open group.

Results: A total of 224 patients were included in the study, 47 and 177 patients underwent MILS and open isolated CL resection, respectively. The overall complication rate was comparable between the two groups; however, severe complication rate (Dindo-Clavien grade ≥ 3) was lower in the MILS group (0% versus 6.8%, P = ns). In-hospital mortality was 0% in both groups and mean hospital stay was significantly shorter in the MILS group (P = 0.01). After selection of 42 MILS and 43 open CL resections by PSM analysis, intraoperative and postoperative outcomes remained similar except for the hospital stay which was not significantly shorter in MILS group.

Conclusions: This multi-institutional cohort study shows that MILS CL resection is feasible and safe. The surgical procedure can be technically demanding compared to open resection, whereas good perioperative outcomes can be achieved in highly selected patients.
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http://dx.doi.org/10.1007/s00464-021-08434-wDOI Listing
March 2021

Ulcerative enteritis. How the extension of ulcerative colitis to small bowel may jeopardize postcolectomy course: a case report and literature review.

Eur J Gastroenterol Hepatol 2021 Apr;33(4):589-594

General and Oncological Surgery Unit.

Intestinal involvement in ulcerative colitis is generally limited to the colon and rectum. We describe a life-threatening case of ulcerative enteritis occurring after colectomy. Other 53 similar cases are reported in the literature. The aim of this narrative review was to focus on ulcerative enteritis characteristics and diagnostic workup. A 25-year-old boy affected by ulcerative colitis underwent a total colectomy in an urgent setting for septic shock. Postoperative course was characterized by elevated ileostomy output, raised up to 10 L/day. Critical clinical conditions required resuscitation therapy. After exclusion of surgical complications, intestinal infections, and histologic specimen revision, the patient underwent endoscopic examination. Ileal biopsies revealed ileal localization of ulcerative colitis. Steroid treatment was finally effective. After literature revision, we classified all cases of ulcerative enteritis in three groups, according to intestinal involvement pattern and timing of clinical manifestation after operation. Out of 54 cases, 18 occurred within 1 month since colectomy (early ileitis), 10 later on (late ileitis) and 26 do not involve ileus (nonileitis). Clinical manifestation is generally severe in the first group and mild and chronic in the others. Differential diagnoses of ulcerative enteritis are represented by infectious, immunological, toxic, and ischemic disorders. Those conditions excluded, ulcerative enteritis can be easily detected by endoscopic biopsies and treated with immunosuppressive agents. Long term surveillance seems important since recurrences are described. In conclusion, clinicians should suspect ulcerative enteritis in all patients with previous colectomy history that develop unexplained gastrointestinal syndromes, in order to avoid therapeutic delay.
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http://dx.doi.org/10.1097/MEG.0000000000002112DOI Listing
April 2021

Liver resection for perihilar cholangiocarcinoma: Impact of biliary drainage failure on postoperative outcome. Results of an Italian multicenter study.

Surgery 2021 Feb 20. Epub 2021 Feb 20.

Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy.

Background: Preoperative biliary drainage may be essential to reduce the risk of postoperative liver failure after hepatectomy for perihilar cholangiocarcinoma. However, infectious complications related to preoperative biliary drainage may increase the risk of postoperative mortality. The strategy and optimal drainage method continues to be controversial.

Methods: This is a retrospective multicenter study including patients who underwent hepatectomy for perihilar cholangiocarcinoma between 2000 and 2016 at 14 Italian referral hepatobiliary centers. The primary end point was to evaluate independent predictors for postoperative outcome in patients undergoing liver resection for perihilar cholangiocarcinoma after preoperative biliary drainage.

Results: Of the 639 enrolled patients, 441 (69.0%) underwent preoperative biliary drainage. Postoperative mortality was 8.9% (12.5% after right-side hepatectomy versus 5.7% after left-side hepatectomy; P = .003). Of the patients, 40.5% underwent preoperative biliary drainage at the first admitting hospital, before evaluation at referral centers. Use of percutaneous preoperative biliary drainage was significantly more frequent at referral centers than at community hospitals where endoscopic preoperative biliary drainage was the most frequent type. The overall failure rate after preoperative biliary drainage was 43.3%, significantly higher at community hospitals than that at referral centers (52.7% v 36.9%; P = .002). Failure of the first preoperative biliary drainage was one of the strongest predictors for postoperative complications after right-side and left-side hepatectomies and for mortality after right-side hepatectomy. Type of preoperative biliary drainage (percutaneous versus endoscopic) was not associated with significantly different risk of mortality.

Conclusion: Failure of preoperative biliary drainage was significantly more frequent at community hospitals and it was an independent predictor for postoperative outcome. Centers' experience in preoperative biliary drainage management is crucial to reduce the risk of failure that is closely associated with postoperative morbidity and mortality.
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http://dx.doi.org/10.1016/j.surg.2021.01.021DOI Listing
February 2021

Multiple hepatocellular carcinoma: Long-term outcomes following resection beyond actual guidelines. An Italian multicentric retrospective study.

Am J Surg 2021 Jan 22. Epub 2021 Jan 22.

Department of Experimental and Clinical Medicine, AOU Careggi, Largo Brambilla 3, 50134, Florence, Italy.

Background: Hepatocellular carcinoma (HCC) is frequently diagnosed as multinodular. This study aims to assess prognostic factors for survival and identify patients with multiple HCC who may benefit from surgery beyond the Barcelona Clinic Liver Cancer classification indications.

Methods: This retrospective study included all the consecutive patients from 4 Italian tertiary centers receiving liver resection for naive multiple HCC between 1990 and 2012 to have a potential follow-up of 5 years.

Results: Included patients were 144. Ninety-day morbidity and mortality rates were 38.3% and 8.3%, respectively. The 5-year overall and disease-free survival rates were 33.3% and 19.1%, respectively. Tumor size <3 cm, bilirubin, Child-Pugh A, BCLC-A stage, being within "up-to-7" criteria, and minor resections resulted in prognostic factors. The Child-Pugh score resulted in an independent prognostic factor.

Conclusions: Surgery may be related to good outcomes in selected patients with multiple HCC.
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http://dx.doi.org/10.1016/j.amjsurg.2021.01.023DOI Listing
January 2021

Predictivity of early and late assessment for post-surgical recurrence of Crohn's disease: Data from a single-center retrospective series.

Dig Liver Dis 2020 Oct 21. Epub 2020 Oct 21.

Gastroenterology Unit, Mauriziano Hospital, Largo Turati 62, I-10128 Turin, Italy. Electronic address:

Background And Aims: Post-surgical recurrence of Crohn's disease (CD) after ileocolonic resection is common. Early identification of features associated with recurrence is a standard procedure of postoperative management, but the prognostic role of such features when detected at later time points is unclear. We compared the predictivity for Crohn's disease recurrence of common clinical-instrumental variables when assessed early (<12 months) or late (>36 months) after surgery.

Methods: This retrospective study considered CD patients who had ileocolonic resection and were followed for a median of 7.6 years. Clinical characteristics, post-surgical therapy, endoscopy recurrence (Rutgeerts' score ≥i2) and ultrasound features were compared between subgroups who had a early or late post-surgical assessment. Univariate and multivariate analyses were done to identify variables associated with recurrence (clinical and surgical).

Results: Of 201 patients, 70 (32%) had a early and 39 (19%) had a late post-surgical assessment. The Early and Late subgroups had similar clinical characteristics. Overall, clinical relapse was observed in 131 patients (66%), surgical relapse in 31 (16%), endoscopic recurrence in 149 (75%) and ultrasonographic recurrence in 132 (66%), without significant differences in frequencies between subgroups. By Cox proportional hazard regression, endoscopic recurrence was a significant predictor of clinical recurrence overall (HR=2.31, P = 0.002) and in the Early (HR=3.85, P = 0.002) but not Late subgroup.

Discussion: The most informative postoperative CD assessment is the one done within the first year of surgery. Later endoscopic evaluations have no prognostic value and should be done only for clinical needs or for research purposes.
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http://dx.doi.org/10.1016/j.dld.2020.09.018DOI Listing
October 2020

Performance of Comprehensive Complication Index and Clavien-Dindo Complication Scoring System in Liver Surgery for Hepatocellular Carcinoma.

Cancers (Basel) 2020 Dec 21;12(12). Epub 2020 Dec 21.

Department of Emergency and Robotic Surgery, ASST Lecco, 23900 Lecco, Italy.

Background: We aimed to assess the ability of comprehensive complication index (CCI) and Clavien-Dindo complication (CDC) scale to predict excessive length of hospital stay (e-LOS) in patients undergoing liver resection for hepatocellular carcinoma.

Methods: Patients were identified from an Italian multi-institutional database and randomly selected to be included in either a derivation or validation set. Multivariate logistic regression models and ROC curve analysis including either CCI or CDC as predictors of e-LOS were fitted to compare predictive performance. E-LOS was defined as a LOS longer than the 75th percentile among patients with at least one complication.

Results: A total of 2669 patients were analyzed (1345 for derivation and 1324 for validation). The odds ratio (OR) was 5.590 (95%CI 4.201; 7.438) for CCI and 5.507 (4.152; 7.304) for CDC. The AUC was 0.964 for CCI and 0.893 for CDC in the derivation set and 0.962 vs. 0.890 in the validation set, respectively. In patients with at least two complications, the OR was 2.793 (1.896; 4.115) for CCI and 2.439 (1.666; 3.570) for CDC with an AUC of 0.850 and 0.673, respectively in the derivation cohort. The AUC was 0.806 for CCI and 0.658 for CDC in the validation set.

Conclusions: When reporting postoperative morbidity in liver surgery, CCI is a preferable scale.
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http://dx.doi.org/10.3390/cancers12123868DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7767420PMC
December 2020

Correspondence on "Benchmark performance of laparoscopic left lateral sectionectomy and right hepatectomy in expert centers".

J Hepatol 2021 Apr 16;74(4):985-986. Epub 2020 Dec 16.

Department of General and Oncological Surgery. Mauriziano Hospital, Turin, Italy.

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http://dx.doi.org/10.1016/j.jhep.2020.11.009DOI Listing
April 2021

Serum amylase elevation following pancreatoduodenectomy with pancreatogastrostomy is strongly associated with major complications.

ANZ J Surg 2021 03 5;91(3):348-354. Epub 2020 Oct 5.

Department of General Surgery, Poliambulanza Foundation Hospital, Brescia, Italy.

Background: Recent reports suggest that, following pancreatic resection, serum amylase elevation (SAE) may be a surrogate indicator of post-operative acute pancreatitis (PAP) and predict post-operative pancreatic fistula (POPF). However, POPF may not account for the majority of complications when pancreatoenteric continuity is restored by pancreatogastrostomy. We aimed to evaluate, among patients undergoing pancreatoduodenectomy with pancreatogastrostomy, the correlation between SAE, radiological changes consistent with PAP and types of post-operative complications overall and specific for pancreatic surgery.

Methods: Perioperative data from 102 patients who underwent pancreatoduodenectomy with pancreatogastrostomy at two Italian hospitals (January 2015-January 2017) were retrospectively analysed. SAE was defined as serum amylase more than three times the normal concentration at post-operative day 1. Post-operative abdominal computed tomography scan was routinely performed and retrospectively and blindly re-assessed for findings consistent with PAP.

Results: Among 102 study patients, overall and major complications and mortality occurred in 68% and 24% and 3% of cases, respectively. POPF and post-pancreatectomy haemorrhage (PPH) occurred in 12% and 21%, respectively. In 75% of patients developing PPH, it occurred in the absence of POPF. SAE occurred in 36 patients who, compared to 66 non-SAE patients, more frequently showed computed tomography scan findings consistent with pancreatic stump inflammation (P = 0.002), confirming association between SAE and PAP. SAE was independently associated with the occurrence of major complications, POPF and PPH (hazard ratio (HR) 3.27, P = 0.032; HR 3.94, P = 0.012; HR 12.26, P = 0.002).

Conclusion: SAE can be considered a valid surrogate of PAP and is strongly associated with a higher rate of post-operative major complications, both overall and specific for pancreatic resection.
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http://dx.doi.org/10.1111/ans.16282DOI Listing
March 2021

Impact of anthropometric data on technical difficulty of laparoscopic liver of resections of segments 7 and 8: the CHALLENGE index.

Surg Endosc 2020 Sep 23. Epub 2020 Sep 23.

Department of General and Oncological Surgery, Umberto I Mauriziano Hospital, Largo Turati, 62-10128, Turin, Italy.

Background: The high technical difficulty of using a laparoscopic approach to reach the posterosuperior liver segments is mainly associated with their poor accessibility. This study was performed to analyze correlations between anthropometric data and intraoperative outcomes.

Study Design: All patients who underwent segmentectomy or wedge laparoscopic liver resection (LLR) of segments seven and/or eight from June 2012 to November 2019 were retrospectively analyzed. The exclusion criteria were intrahepatic cholangiocarcinoma, associated resection, multiple concomitant LLR, redo resection, and lack of preoperative imaging. Anthropometric data were correlated with intraoperative outcomes.

Results: Forty-one patients (wedge resection, n = 32; segmentectomy, n = 9) were analyzed. A strong correlation was found between the craniocaudal liver diameter (CCliv) and liver volume (r = 0.655, p < 0.001). The anteroposterior liver diameter was moderately correlated with both the laterolateral abdominal diameter (LLabd) (r = 0.372, p = 0.008) and anteroposterior abdominal diameter (r = 0.371, p = 0.008). The body mass index (BMI) was not correlated with liver diameters. Women had a longer CCliv (p = 0.002) and shorter LLabd (p < 0.001) than men. The liver and abdominal measurements were combined to reduce this sex-related disparity. The CCliv/LLabd ratio (CHALLENGE index) was significantly correlated with the time of transection (r = 0.382, p = 0.037) and blood loss (r = 0.352, p = 0.029). The association between the CHALLENGE index and intraoperative blood loss was even stronger when considering only anatomical resection (r = 0.577, p = 0.048). A CHALLENGE index of > 0.4 (area under the curve, 0.757; p = 0.046) indicated a higher bleeding risk. The BMI predicted no intraoperative outcomes.

Conclusion: Anthropometric data rather than the BMI can help anticipate the difficulty of LLR of segments seven and eight.
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http://dx.doi.org/10.1007/s00464-020-07993-8DOI Listing
September 2020

Stratification of Major Hepatectomies According to Their Outcome: Analysis of 2212 Consecutive Open Resections in Patients Without Cirrhosis.

Ann Surg 2020 11;272(5):827-833

Department of Medical Sciences, Cancer Epidemiology Unit, University of Torino and CPO-Piemonte, Torino, Italy.

Objective: To stratify major hepatectomies (MajHs) according to their outcomes.

Summary Of Background Data: MajHs are associated with non-negligible operative risks, but they include a wide range of procedures. Detailed depiction of the outcomes of different MajHs is the basis for a new classification of liver resections.

Methods: We retrospectively considered patients that underwent hepatectomy in 17 high-volume centers. Patients with an associated digestive/biliary resection were excluded. We analyzed open MajHs in non-cirrhotic patients. MajHs were classified according to the Brisbane nomenclature. Right hepatectomies (RHs) were reference standards. Outcomes were adjusted for potential confounders, including indication, liver function, preoperative portal vein embolization, and enrolling center.

Results: We analyzed a series of 2212 patients. In comparison with RH, left hepatectomy had lower mortality [0.6% vs 2.2%, odds ratio (OR) = 0.25], severe morbidity (11.7% vs 14.4%, OR = 0.62), and liver failure rates (2.1% vs 11.6%, OR = 0.16). Left hepatectomy+Sg1 and mesohepatectomy+/-Sg1 had outcomes similar to RH, except for higher bile leak rate (31.3% and 13.5% vs 6.7%, OR = 4.36 and OR = 2.29). RH + Sg1 had slightly worse outcomes than RH. Right and left trisectionectomies had higher mortality (5.0% and 7.3% vs 2.2%, OR = 2.07 and OR = 2.71) and liver failure rates than RH (19.0% and 22.0% vs 11.6%, OR = 2.03 and OR = 2.21). Left trisectionectomy had even higher severe morbidity (25.6% vs 14.4%, OR = 2.07) and bile leak rates (14.6% vs 6.7%, OR = 2.31).

Conclusions: The term "major hepatectomy" includes resections having heterogeneous outcome. Different MajHs can be stratified according to their mortality, severe morbidity, liver failure, and bile leak rates.
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http://dx.doi.org/10.1097/SLA.0000000000004338DOI Listing
November 2020

The disappearing of emergency surgery during the COVID 19 pandemic. Fact or fiction?

Br J Surg 2020 Oct 1;107(11):e508-e509. Epub 2020 Sep 1.

Department of General and Oncological Surgery, Azienda Ospedaliera Ordine Mauriziano "Umberto I", Turin, Italy.

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http://dx.doi.org/10.1002/bjs.11971DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7929341PMC
October 2020

Laparoscopic right posterior anatomic liver resections with Glissonean pedicle-first and venous craniocaudal approach.

Surg Endosc 2021 Jan 24;35(1):449-455. Epub 2020 Aug 24.

Department of General and Oncological Surgery, Ospedale Mauriziano "Umberto I", Largo Turati 62, 10128, Turin, Italy.

Background: Laparoscopic segment 7 segmentectomy and segment 6-7 bisegmentectomy are challenging resections because of the posterior position and the lack of landmarks. The anatomy of the right posterior Glissonean pedicle and the caudal view of laparoscopy make such resections suitable for the Glissonean pedicle-first approach.

Methods: The study population included all consecutive patients treated with laparoscopic liver resection from August 2019 to February 2020. The approach is based on the ultrasonographic identification of the right posterior or segmental pedicle from the dorsal side of the liver after complete mobilization. The pedicle of interest is isolated through mini-hepatotomy and clamped. The segment anatomy is defined by ischemia. The transection starts from the ventral side, close to the right hepatic vein that is exposed and followed craniocaudally.

Results: Ten patients underwent anatomical laparoscopic resection of right posterolateral segments. There were 7 colorectal liver metastases, 2 hepatocellular carcinoma, and 1 biliary cysto-adenoma. Five patients underwent Sg7 resection, one patient underwent a Sg7 subsegmentectomy, and 4 underwent Sg6-7 bisegmentectomy. The Glissonean pedicle-first approach was feasible in eight patients. The craniocaudal approach to the RHV was feasible in six patients, not indicated in three cases and was abandoned in one patient for technical difficulty. There was no operative morbidity or mortality. Median post-operative hospital stay was 5 days.

Conclusions: The Glissonean pedicle-first approach is safe and effective for laparoscopic anatomic resections of the right posterior sector. The craniocaudal approach to right hepatic vein from the ventral side is a convenient procedure to follow the segmental anatomy deep in the parenchyma.
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http://dx.doi.org/10.1007/s00464-020-07916-7DOI Listing
January 2021

Comparison of laparoscopic ultrasound and liver-specific magnetic resonance imaging for staging colorectal liver metastases.

Surg Endosc 2020 Jul 24. Epub 2020 Jul 24.

Department of General and Oncological Surgery, Umberto I Mauriziano Hospital, Largo Turati 62, 10128, Turin, Italy.

Background: Intraoperative liver ultrasound appears superior to liver-specific contrast-enhanced magnetic resonance imaging (MRI) to stage colorectal liver metastases (CRLMs). Most of the data come from studies on open surgery. Laparoscopic ultrasound (LUS) is technically demanding and its reliability is poor investigated. Aim of the study was to assess the accuracy of LUS staging for CRLMs compared to MRI.

Methods: All patients with CRLMs scheduled for laparoscopic liver resection (LLR) between 01/2010 and 06/2019 who underwent preoperative MRI were considered for the study. LUS and MRI performance was compared on a patient by patient basis. Reference standards were final pathology and 6 months follow-up results.

Results: Amongst 189 LLR for CRLMs, 146 met inclusion criteria. Overall, 391 CRLMs were preoperatively detected by MRI. 24 new nodules in 16 (10.9%) patients were found by LUS and resected. Median diameter of new nodules was 5.5 mm (2-10 mm) and 10 (41.6%) were located in the hepatic dome. Pathology confirmed 17 newly detected malignant nodules (median size 4 mm) in 11 (7.5%) patients. Relationships between intrahepatic vessels and tumours differed between LUS and MRI in 9 patients (6.1%). Intraoperative surgical strategy changed according LUS findings in 19 (13%) patients, requiring conversion to open approach in 3 (15.8%) of them. The sensitivity of LUS was superior to MRI (93.1% vs 85.6% whilst specificity was similar (98.6% MRI vs 96.5% LUS).

Conclusions: Laparoscopic liver ultrasound improves liver staging for CRLMs compared to liver-specific MRI.
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http://dx.doi.org/10.1007/s00464-020-07817-9DOI Listing
July 2020

Telephone-based postoperative surveillance protocol for hepatobiliary cancer during the COVID-19 outbreak.

Updates Surg 2020 06 10;72(2):317-318. Epub 2020 Jun 10.

Department of General and Oncological Surgery, Mauriziano Hospital, Turin, Italy.

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http://dx.doi.org/10.1007/s13304-020-00829-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7284684PMC
June 2020

The Italian National Registry for minimally invasive pancreatic surgery: an initiative of the Italian Group of Minimally Invasive Pancreas Surgery (IGoMIPS).

Updates Surg 2020 Jun 29;72(2):379-385. Epub 2020 May 29.

Università di Pisa, Pisa, Italy.

The value of minimally invasive pancreatic surgery (MIPS) is still uncertain, despite the growing number of publications, including reviews and meta-analyses, and the quick diffusion of these procedures worldwide. The Italian Group of Minimally Invasive Pancreas Surgery (IGoMIPS) was created under the auspices of three Scientific Societies: Associazione Italiana Studio Pancreas (AISP), Associazione Italiana Chirurgia Epato-Bilio-Pancreatica (AICEP, former IT-IHPBA), and Società Italiana di Chirurgia Endoscopica (SICE). The main aim of IGoMIPS is to develop and implement a national registry for MIPS. IGoMIPS was founded on February 22, 2019 in Pisa. The IGoMIPS registry became operational in September 2019, following approval by the Ethic Committees of founding Institutions, inscription into the Registry of Patient Registries (RoPR), and a wrap-up meeting held in Bologna during the Annual Congress of the Italian Surgical Society. During this meeting IGoMIPS members approved that the Italian Registry will provide data to the European Registry, while retaining the right to analyze and publish Italian data. An audience survey was also conducted to obtain information on perceived value and current implementation of MIPS in founding Institutions. MIPS is performed in 94.7% of IGoMIPS centers, including pancreaticoduodenectomy in 42.1%. Robotic assistance was employed in 52.6% of Institutions. The annual volume of MIPS was 6-10 cases in 38.9% of the centers, 11-20 cases in 16.7%, 21-30 cases in 22.2%, and > 30 cases in 22.2%. The registry was felt to be extremely important for both safety improvement and educational purposes by 94.5% of the centers.
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http://dx.doi.org/10.1007/s13304-020-00808-4DOI Listing
June 2020

Vascular Resection During Hepatectomy for Liver Malignancies. Results from a Tertiary Center using Autologous Peritoneal Patch for Venous Reconstruction.

World J Surg 2020 09;44(9):3100-3107

Department of General and Oncological Surgery, Ospedale Mauriziano "Umberto I" Hospital, Largo Turati, 62, 10128, Turin, Italy.

Background: To evaluate early outcomes of venous reconstruction with peritoneal patch (PP) during resection for hepatic malignancies.

Methods: Since May 2015, PP was considered as the first option for venous reconstruction in the case of lateral resection. Between May 2015 and June 2019, 579 consecutive hepatectomies for malignancies were performed at our institution. Among 27 patients requiring venous resection, PP was used in 22, who were included in the present study. Data from a prospectively collected database were analysed.

Results: Tumour types were ten colorectal metastases (CRLM), six intrahepatic cholangiocarcinomas, four hilar cholangiocarcinomas, one hepatocellular carcinoma and one gallbladder carcinoma. Hepatectomies were major in 50% of cases. Eleven patients had hepatic vein resections, eight portal vein and three inferior vena cava. Venous reconstruction enabled resection in 12 (54.5%) patients, otherwise non-resectable. Among CRLM, the venous reconstruction allowed avoidance of major resection in eight (80%) cases. Median operative time was 456 min (range 270-960). Blood loss was a median 300 cc (range 40-1500), and blood transfusions were required in three patients (13.6%). At pathological examination, venous infiltration was confirmed in 14 (63.6%) patients. No vascular complications related to the patch were recorded. Post-operative major (Dindo III/IV) complications were observed in two (9%) patients. One patient died because of liver failure without vascular thrombosis and one due to biliary fistula complicated by arterial bleeding. Overall, post-operative mortality was 9% (2/22).

Conclusions: Venous reconstruction with peritoneal patch during hepatectomy for malignancies can feasibly allow resection in otherwise unresectable patients and decrease the rate of major resection in colorectal liver metastases.
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http://dx.doi.org/10.1007/s00268-020-05564-5DOI Listing
September 2020

Downstaging unresectable hepatocellular carcinoma by radioembolization using 90-yttrium resin microspheres: a single center experience.

J Gastrointest Oncol 2020 Feb;11(1):84-90

Department of General and Oncological Surgery, Mauriziano Hospital, Turin, Italy.

Background: Only one third of patients with hepatocellular carcinoma can benefit from curative treatments at the time of first diagnosis. Tumor downstaging by radioembolization may enable initially unresectable hepatocellular carcinoma (HCC) to be treated with surgery lengthening survival.

Methods: From June 2011 through June 2014, all patients with a first diagnosis of unresectable HCC with intrahepatic portal vein thrombosis were treated in our center with radioembolization using 90-yttrium resin microspheres. A 3-year enrollment period and a 5-year follow-up were planned to adequately investigate survivals.

Results: Twenty-four patients were enrolled, five were downstaged to surgery, eight did not reach downstaging but achieved partial response or stable disease, and eleven showed HCC progression despite radioembolization. High tumor absorbed radiation doses (454 . 248 and 138 Gy, P=0.005) and low serum AFP levels (53 . 1,447 and 4,603 ng/mL, P=0.05) were the variables significantly associated with successful downstaging. Mean and median survivals were 54, 30 and 11 months and 70, 24 and 11 months in the three groups respectively. No severe side effects were registered.

Conclusions: In our center, about 20% of patients with locally advanced unresectable hepatocellular carcinoma were successfully downstaged to surgery after radioembolization. This strategy increases survival and is associated with an excellent safety profile.
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http://dx.doi.org/10.21037/jgo.2019.06.01DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7052761PMC
February 2020

Preoperative predictors of liver decompensation after mini-invasive liver resection.

Surg Endosc 2021 Feb 2;35(2):718-727. Epub 2020 Mar 2.

Department of Gastrointestinal Surgery and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori Di Milano, Via Venezian 1, 20133, Milan, Italy.

Background: Post-hepatectomy liver failure (PHLF) represents the most frequent complication after liver surgery, and the most common cause of morbidity and mortality. Aim of the study is to identify the predictors of PHLF after mini-invasive liver surgery in cirrhosis and chronic liver disease, and to develop a model for risk prediction.

Methods: The present study is a multicentric prospective cohort study on 490 consecutive patients who underwent mini-invasive liver resection from the Italian Registry of Mini-invasive Liver Surgery (I go MILS). Retrospective additional biochemical and clinical data were collected.

Results: On 490 patients (26.5% females), PHLF occurred in 89 patients (18.2%). The only independent predictors of PHLF were Albumin-Bilirubin (ALBI) score (OR 3.213; 95% CI 1.661-6.215; p < .0.0001) and presence of ascites (OR 3.320; 95% CI 1.468-7.508; p = 0.004). Classification and regression tree (CART) modeling led to the identification of three risk groups: PHLF occurred in 23/217 patients with ALBI grade 1 (10.6%, low risk group), in 54/254 patients with ALBI score 2 or 3 and absence of ascites (21.3%, intermediate risk group) and in 12/19 patients with ALBI score 2 or 3 and evidence of ascites (63.2%, high risk group), p < 0.0001. The three groups showed a corresponding increase in postoperative complications (20.0%, 27.5% and 66.7%), Comprehensive Complication Index (5.1 ± 11.1, 6.0 ± 10.9 and 18.8 ± 18.9) and hospital stay (6.0 ± 4.0, 6.0 ± 6.0 and 8.0 ± 5.0 days).

Conclusion: The risk of PHLF can be stratified by determining two easily available preoperative factors: ALBI and ascites. This model of risk prediction offers an objective instrument for a correct clinical decision-making.
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http://dx.doi.org/10.1007/s00464-020-07438-2DOI Listing
February 2021

A retrospective study on efficacy of the ERAS protocol in patients undergoing surgery for Crohn disease: A propensity score analysis.

Dig Liver Dis 2020 06 19;52(6):625-629. Epub 2020 Feb 19.

Department of Chirurgia Generale e Oncologica, Ospedale Mauriziano Umberto I, Torino, Italy.

Background: Enhanced Recovery After Surgery (ERAS) offers many benefits for patients with colorectal cancer. However, its application to patients with Crohn's disease (CD) is questioned.

Aim: The aim of this propensity-matched study was to validate the results of ERAS protocol on CD patients.

Methods: Patients undergoing ileocolic resection for primary or relapsed CD from 2007 to 2018 were retrospectively analyzed and propensity-matched into two equal groups (ERAS vs standard of care). Demographic characteristics, length of stay, bowel function, oral intake, and perioperative morbidity were analyzed.

Results: Ninety four out of 299 patients were selected for analysis. No significant difference was observed for age, gender, American Society of Anesthesiologists score, body mass index, previous surgery and therapy, operative time and laparoscopy. The median length of stay in ERAS and non-ERAS groups was 6 and 8 days (p < 0.001). Median postoperative days of first bowel movement and solid oral intake were day 1 and day 2 p < 0,001, and day 2 and day 4.5 p < 0,001 in ERAS and non-ERAS group, respectively. No statistically differences in other postoperative outcomes were shown.

Conclusions: ERAS implementation showed decreased length of stay, faster bowel function restoration and earlier solid oral intake in patients who underwent laparoscopic or open ileocolic resection for primary or relapsing CD.
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http://dx.doi.org/10.1016/j.dld.2020.01.006DOI Listing
June 2020

Comparison and validation of three difficulty scoring systems in laparoscopic liver surgery: a retrospective analysis on 300 cases.

Surg Endosc 2020 12 16;34(12):5484-5494. Epub 2020 Jan 16.

Department of General and Oncological Surgery, Mauriziano Hospital, Turin, Italy.

Background: Difficulty scores (DSs) have been proposed to rate laparoscopic liver resection (LLR) technical difficulty increasing surgical safety. The aim of the study was to validate three DSs (Hasegawa, Halls and Kawaguchi) and compare their ability to predict technical difficulty and postoperative outcomes.

Materials And Methods: All patients who underwent LLR from January 2006 to January 2019 were analyzed. Exclusion criteria were cyst fenestrations, thermal ablation, missing data for the computation of the DS and a follow-up < 90 days.

Results: The population comprised 300 patients. The DS distribution in the study population was: Halls low 55 (18.3%), moderate 82 (27.3%), high 111 (37%) and extremely high 52 (17.3%); Hasegawa low 130 (43.3%), medium 105 (35%) and high 65 (21.7%); Kawaguchi Grade I 194 (64.7%), Grade II 47 (15.7%) and Grade III 59 (19.7%). Hasegawa and Kawaguchi showed the strongest correlation (r = 0.798, p < 0.001). Technical complexity, evaluated using the Pringle maneuver, Pringle time, blood loss and operative time, increased significantly with Hasegawa and Kawaguchi score classes (p < 0.001 for all comparisons). None of the scores properly stratified postoperative complications. The highest Kawaguchi (23.7% grade III vs. 13.7% grades I and II, p = 0.057) and Hasegawa (24.6% high vs. 13.2% low/medium, p = 0.025) classes had a higher overall morbidity rate than medium-low ones.

Conclusions: Kawaguchi and Hasegawa scores predicted LLR's technical difficulty. None of the scores discriminated the postoperative complication risk of low classes compared with medium ones.
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http://dx.doi.org/10.1007/s00464-019-07345-1DOI Listing
December 2020

Hepatopancreatoduodenectomy -a controversial treatment for bile duct and gallbladder cancer from a European perspective.

HPB (Oxford) 2020 Sep 30;22(9):1339-1348. Epub 2019 Dec 30.

Department of Surgery, Amsterdam University Medical Centres, location AMC, Amsterdam, the Netherlands.

Background: Hepatopancreatoduodenectomy (HPD) is an aggressive operation for treatment of advanced bile duct and gallbladder cancer associated with high perioperative morbidity and mortality, and uncertain oncological benefit in terms of survival. Few reports on HPD from Western centers exist. The purpose of this study was to evaluate safety and efficacy for HPD in European centers.

Method: Members of the European-African HepatoPancreatoBiliary Association were invited to report all consecutive patients operated with HPD for bile duct or gallbladder cancer between January 2003 and January 2018. The patient and tumor characteristics, perioperative and survival outcomes were analyzed.

Results: In total, 66 patients from 19 European centers were included in the analysis. 90-day mortality rate was 17% and 13% for bile duct and gallbladder cancer respectively. All factors predictive of perioperative mortality were patient and disease-specific. The three-year overall survival excluding 90-day mortality was 80% for bile duct and 30% for gallbladder cancer (P = 0.013). In multivariable analysis R0-resection had a significant impact on overall survival.

Conclusion: HPD, although being associated with substantial perioperative mortality, can offer a survival benefit in patient subgroups with bile duct cancer and gallbladder cancer. To achieve negative resection margins is paramount for an improved survival outcome.
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http://dx.doi.org/10.1016/j.hpb.2019.12.008DOI Listing
September 2020

Preoperative risk score for prediction of long-term outcomes after hepatectomy for intrahepatic cholangiocarcinoma: Report of a collaborative, international-based, external validation study.

Eur J Surg Oncol 2020 04 5;46(4 Pt A):560-571. Epub 2019 Nov 5.

Department of Hepatobiliary and Liver Transplantation Surgery, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, France. Electronic address:

Purpose: A preoperative risk score (PRS) to predict outcome of patients with intrahepatic cholangiocarcinoma treated by liver surgery could be clinically relevant.To assess accuracy for broadly adoption, external validation of predictive models on independent datasets is crucial. The objective of this study was to externally validate the score for prediction of long-term outcomes after liver surgery for intrahepatic cholangiocarcinoma proposed by Sasaki et al. and based on preoperative albumin, neutrophil-to-lymphocytes-ratio, CA19-9 and tumor size.

Methods: Patients treated by liver surgery for intrahepatic cholangiocarcinoma at 11 international HPB centers from 2001 to 2018 were included in the external validation cohort. Harrell's c-index and Hosmer-Lemeshow analyses were used to test PRS discrimination and calibration. Kaplan-Meier curve for risk groups as described in the original study were displayed.

Results: A total of 355 patients with 174 deaths during the follow-up period (median = 41.7 months, IQR 32.8-50.6) were included. The median PRS value was 14.7 (IQR 10.7-20.6), with normal distribution across the cohort. A Cox regression on PRS covariates found coefficients similar to those of the derivation cohort, except for tumor size. Measures of discrimination estimated by Harrell's c-index was 0.61(95%CI:0.56-0.67) and Hosmer-Lemeshow p = 0.175. The Kaplan-Meyer estimation showed reasonable discrimination across risk groups, with 5years survival rate ranging from 20.1% to 0%.

Conclusion: In this external validation cohort, the PRS had mild discrimination and poor calibration performance, similarly to the original publication. Nevertheless, its ability to identify different classes of risk is clinically useful, for a better tailoring of a therapeutic strategy.
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http://dx.doi.org/10.1016/j.ejso.2019.10.041DOI Listing
April 2020

Intraoperative Ultrasound Staging for Colorectal Liver Metastases in the Era of Liver-Specific Magnetic Resonance Imaging: Is It Still Worthwhile?

J Oncol 2019 22;2019:1369274. Epub 2019 Sep 22.

Department of General and Oncological Surgery, Ospedale Mauriziano "Umberto I", Torino, Italy.

Background: To assess the efficacy of intraoperative ultrasound (IOUS) compared with liver-specific magnetic resonance imaging (MRI) in patients with colorectal liver metastases (CRLMs).

Methods: From January 2010 to December 2017, 721 patients underwent MRI as a part of preoperative workup within 1 month before hepatectomy and were considered for the study. Early intrahepatic recurrence (relapse at cut surface excluded) was assessed 6 months after the resection and was considered as residual disease undetected by IOUS and/or MRI. IOUS and MRI performance was compared on a patient-by-patient basis. Long-term results were also studied.

Results: A total of 2845 CRLMs were detected by MRI, and the median number of CRLMs per patient was 2 (1-31). Preoperative chemotherapy was administered in 489 patients (67.8%). In 177 patients, 379 new nodules were intraoperatively found and resected. Among 379 newly identified nodules, 317 were histologically proven CRLMs (11.1% of entire series). The median size of new CRLMs was 6 ± 2.5 mm. Relationships between intrahepatic vessels and tumors differed between IOUS and MRI in 128 patients (17.7%). The preoperative surgical plan was intraoperatively changed for 171 patients (23.7%). Overall, early intrahepatic recurrence occurred in 8.7% of cases. To assess the diagnostic performance, 24 (3.3%) recurrences at the cut surface were excluded; thus, 5.4% of early relapses were considered for analysis. The sensitivity of IOUS was superior to MRI (94.5% vs 75.1%), while the specificity was similar (95.7% vs 95.9%). Multivariate analysis at the hepatic dome or subglissonian and mucinous histology revealed predictive factors of metastases missing at MRI. The 5-year OS (52.1% vs 37.8%, =0.006) and DF survival (45.1% vs 33%, =0.002) were significantly worse among patients with new CRLMs than without.

Conclusions: IOUS improves staging in patients undergoing resection for CRLMs even in the era of liver-specific MRI. Intraoperative detection of new CRLMs negatively affects oncologic outcomes.
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http://dx.doi.org/10.1155/2019/1369274DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6778901PMC
September 2019

Minor Hepatectomies: Focusing a Blurred Picture: Analysis of the Outcome of 4471 Open Resections in Patients Without Cirrhosis.

Ann Surg 2019 11;270(5):842-851

Department of Medical Sciences, Cancer Epidemiology Unit, University of Torino and CPO-Piemonte, Torino, Italy.

Objective: To elucidate minor hepatectomy (MiH) outcomes.

Summary Background Data: Liver surgery has moved toward a parenchyma-sparing approach, favoring MiHs over major resections. MiHs encompass a wide range of procedures.

Methods: We retrospectively evaluated consecutive patients who underwent open liver resections in 17 high-volume centers.

Exclusion Criteria: cirrhosis and associated digestive/biliary resections. Resections were classified as (Brisbane nomenclature): limited resections (LR); (mono)segmentectomies/bisegmentectomies (Segm/Bisegm); right anterior and right posterior sectionectomies (RightAnteriorSect/RightPosteriorSect). Additionally, we defined: complex LRs (ComplexLR = LRs with exposed vessels); postero-superior segmentectomies (PosteroSuperiorSegm = segment (Sg)7, Sg8, and Sg7+Sg8 segmentectomies); and complex core hepatectomies (ComplexCoreHeps = Sg1 segmentectomies and combined resections of Sg4s+Sg8+Sg1). Left lateral sectionectomies (LLSs, n = 442) and right hepatectomies (RHs, n = 1042) were reference standards. Outcomes were adjusted for potential confounders.

Results: Four thousand four hundred seventy-one MiHs were analyzed. Compared with RHs, MiHs had lower 90-day mortality (0.5%/2.2%), severe morbidity (8.6%/14.4%), and liver failure rates (2.4%/11.6%, P < 0.001), but similar bile leak rates. LR and LLS had similar outcomes. ComplexLR and Segm/Bisegm of anterolateral segments had higher bile leak rates than LLS rates (OR = 2.35 and OR = 3.24), but similar severe morbidity rates. ComplexCoreHeps had higher bile leak rates than RH rates (OR = 1.94); the severe morbidity rate approached that of RH. PosteroSuperiorSegm, RightAnteriorSect, and RightPosteriorSect had severe morbidity and bile leak rates similar to RH rates. MiHs had low liver failure rates, except RightAnteriorSect (vs LLS OR = 4.02).

Conclusions: MiHs had heterogeneous outcomes. Mortality was low, but MiHs could be stratified according to severe morbidity, bile leak, and liver failure rates. Some MiHs had postoperative outcomes similar to RH.
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http://dx.doi.org/10.1097/SLA.0000000000003493DOI Listing
November 2019

Surgical Management of Hepatic Benign Disease: Have the Number of Liver Resections Increased in the Era of Minimally Invasive Approach? Analysis from the I Go MILS (Italian Group of Minimally Invasive Liver Surgery) Registry.

J Gastrointest Surg 2020 10 10;24(10):2233-2243. Epub 2019 Sep 10.

Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, L.go A. Gemelli, 8, 00168, Rome, Italy.

Background: Increased expertise with minimally invasive liver surgery (MILS) could cause an unjustified extension of indications to resect liver benign disease (BD). The aim of this study was to evaluate the operative risk of MILS for BD and if implementation and diffusion of MILS have widened indications for BD resection.

Methods: A prospective study including centers with > 6 MILS for BD, enrolled in the I Go MILS registry from January 2015 to October 2016. Cysts fenestrations were excluded.

Results: Eight hundred eighteen MILS were performed in 15 centers. One hundred seventy-three of these (21.1%) were for BD: conversion rate was 6.9%, postoperative mortality and morbidity rates were 0 and 13.9%. During the same period, 3713 liver resections (open + MILS) were performed and 407 (11.0%) were for BD. A time-trend analysis showed that the total number of MILS and the number of MILS for malignant disease significantly increased, but this increasing trend was not documented for the number of MILS for BD, which remained stable during the study period of time. This trend was confirmed for the overall rate of resected BD (open + MILS) that remained stable.

Discussion: BD represents a valid indication for MILS. For BD, 21.1% of MILS was performed, rate significantly lower than that previously reported in Italy. Although an evident growth of the use of MILS was observed during the time period analysis in Italy, this trend did not correspond to an increased number of MILS for BD, and the overall rate of resected BD was comparable to that reported in previous large open series.
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http://dx.doi.org/10.1007/s11605-019-04260-7DOI Listing
October 2020

Intraoperative ultrasonography in patients undergoing surgery for Crohn's disease. Prospective evaluation of an innovative approach to optimize staging and treatment planning.

Updates Surg 2019 Jun 28;71(2):305-312. Epub 2019 Jun 28.

Department of HPB and Digestive Surgery, Ospedale Mauriziano Umberto I, Turin, Italy.

Percutaneous ultrasonography (perc-US) and magnetic resonance enterography (e-MR) are the present standards for staging patients with Crohn's disease (CD). However, intraoperative data still have some discrepancies with preoperative ones. The contribution of intraoperative ultrasonography (IOUS) has never been evaluated. Sixty-five consecutive patients scheduled for ileal/colonic resection for CD between 2010 and 2014 were prospectively enrolled. All patients had perc-US, e-MR and IOUS. Data from different imaging modalities were compared. The reference standard was the final pathology. Surgery was scheduled because of intestinal obstruction (n = 31 patients), inflammatory mass (n = 21), fistula (n = 10), or abdominal pain/sepsis (n = 3). Fourteen (21.5%) patients had a major discrepancy between preoperative and intraoperative data that required a modification of the surgical planning (five additional ileal lesions, three unknown ileo-sigmoid fistulas, and six not confirmed CD sites). IOUS correctly staged CD in all but one patients (missed ileo-colonic fistula). Pathology data differed from Perc-US data in 13 (20%) patients, from e-MR data in 14 (21.5%), and from IOUS data in one (1.5%). The sensitivity of Perc-US, e-MR and IOUS was: for the identification of CD sites 84.2%, 86.1%, and 100%; for the identification of stenoses 86.8%, 86.8%, and 100%; for the identification of fistulas 75.0%, 81.3%, and 93.8%, respectively. IOUS contributed to the surgical planning in 8 (12.3%) patients. IOUS is a safe, feasible and easy-to-perform procedure that optimizes staging of CD and, in some patients, helps to better define the treatment strategy. It could be helpful to face complex disease presentations on the basis of objective and reproducible data.
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http://dx.doi.org/10.1007/s13304-019-00668-7DOI Listing
June 2019

Impact of primary tumor location on patterns of recurrence and survival of patients undergoing resection of liver metastases from colon cancer.

HPB (Oxford) 2020 01 22;22(1):116-123. Epub 2019 Jun 22.

Department of General and Oncological Surgery, Mauriziano Hospital, Turin, Italy.

Background: Several studies have described a worse prognosis for right-sided colon cancer compared to left-sided. The aim of this study was to compare patterns of recurrence and survival following resection of liver metastases (LM) from right-sided (RS) versus left-sided (LS) colon cancer.

Methods: Patients undergoing resection for colon cancer LM between 2000 and 2017 were analyzed. Rectal cancer, multiple primaries and unknown location were excluded.

Results: Out of 995 patients, 686 fulfilled inclusion criteria (RS-LM = 322, LS-LM = 364). RS colon cancer had higher prevalence of metastatic lymph nodes (67.4% vs. 57.1%, P = 0.008). RS-LM were more often mucinous (16.8% vs. 8.5%, P = 0.001) and G3 (58.3% vs. 48.9%, P = 0.014). 451 (65.7%) patients experienced recurrence (RS-LM 68.9% vs. LS-LM 62.9%). In RS-LM group, recurrence was more often encephalic (2.3% vs. 0%, P = 0.029) and at multiple sites (34.2% vs. 23.5%, P = 0.012). The rate of re-resection was lower in RS-LM patients (27.9% vs. 37.5%, P = 0.024). Multivariate analysis showed RS-LM to have worse 5-year overall (35.8% vs. 51.2%, P = 0.002) and disease-free survival (26% vs. 43.6%, P = 0.002).

Conclusions: RS-LM is associated with worse survival and aggressive recurrences, with lower chance of re-resection.
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http://dx.doi.org/10.1016/j.hpb.2019.05.014DOI Listing
January 2020

Ultrasound Liver Map Technique for Laparoscopic Liver Resections.

World J Surg 2019 10;43(10):2607-2611

Department of General and Oncological Surgery, Mauriziano Hospital "Umberto I", Largo Turati, 62, 10128, Turin, Italy.

Background: Laparoscopic liver resection (LLR) is reported as a safe procedure with potential advantages over open surgery albeit with inherent limitations, such as loss of haptic perception and spatial orientation. Ultrasound is considered the best tool to identify anatomic landmarks and the transection plane during liver surgery. The aim of this study was to analyse the outcomes of LLR performed with a standardized US guidance technique.

Methods: We have standardized a 4-step technique for ultrasound-guided LLR: (1) compose a 3-D mind map by studying relationships among lesions and surrounding anatomic structures, (2) sketch the map on the liver surface, (3) check, and (4) correct the transection plane in real time.

Results: Between 01/2006 and 12/2016, 190 consecutive patients treated with US-guided LLR were analysed. The indications for LLR included malignant tumours in 148 patients (81.8%). The procedures were classified according to a difficulty scale. There were 18 major hepatectomies (9.9%), 80 anatomic bi- and monosegmentectomies (44.2%), and 101 non-anatomic resections (55.8%). Redo resection was performed in 17 patients (9.4%), and multiple liver resections were performed in 25 patients (24.7%). Median intraoperative blood loss was 100 ± 154 mL. Overall and major morbidity rates were 14.9% and 1.6%, respectively. Mortality was nil.

Conclusions: Ultrasound liver map technique enables planning and real-time guidance during laparoscopic liver resections.
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http://dx.doi.org/10.1007/s00268-019-05046-3DOI Listing
October 2019

Outcomes of enhanced one-stage ultrasound-guided hepatectomy for bilobar colorectal liver metastases compared to those of ALPPS: a multicenter case-match analysis.

HPB (Oxford) 2019 10 9;21(10):1411-1418. Epub 2019 May 9.

Department of General Surgery, Maggiore Hospital, Bologna, Italy. Electronic address:

Background: In case of bilobar colorectal liver metastases (CLM) associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been proposed. Enhanced one-stage ultrasound-guided hepatectomy (e-OSH) may represent a further solution for these patients. Aim of this study was to compare by case-match analyses the outcome of ALPPS and e-OSH.

Methods: Between 2012 and 2017, patients undergoing ALPPS for bilobar CLM were matched 1:2 with patients receiving e-OSH. Patients were matched according to the Fong Score (1-3/4-5), the number of CLM (3-7/≥8), the number of CLM in the left liver (1-2/≥3) and preoperative chemotherapy. All the patients in the e-OSH group had a right -sided major vascular contact. The main endpoints of the study were perioperative outcomes, overall (OS) and disease-free survival (DFS).

Results: Seventy-eight patients were selected (26 ALPPS and 52 e-OSH) based on matching process. The two treatments differed significantly in major morbidity (26.9% ALPPS vs 7.7% e-OSH, p = 0.017). Median OS (31.7 vs 32.6 months) and DFS (10.6 vs 7.8 months) were comparable between the two groups.

Conclusions: This study demonstrates that ALPPS and e-OSH for bilobar CLM achieve comparable long-term results, despite higher morbidity reported after ALPPS. These findings should drive to reposition e-OSH in managing these patients.
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http://dx.doi.org/10.1016/j.hpb.2019.04.001DOI Listing
October 2019