Publications by authors named "Andrea Coratti"

98 Publications

Pancreaticoduodenectomy in octogenarians: The importance of "biological age" on clinical outcomes.

Surg Oncol 2021 Nov 24;40:101688. Epub 2021 Nov 24.

Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy; Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168, Rome, Italy.

Introduction: With the prolongation of life expectancy, an increasing number of elderly patients are evaluated for pancreatic surgery. However, the influence of increasing age on outcomes after pancreaticoduodenectomy (PD) is still unclear, especially in octogenarians. Aim of this study is to evaluate the perioperative characteristics and outcomes of octogenarians undergoing PD.

Methods: Data for 812 patients undergoing PD between 2019 and 2020 in 10 referral centers in Italy were reviewed. Patients aged 80 years or older were matched based on nearest neighbor propensity scores in a 1:1 ratio to patients younger than 80 years. Propensity scores were calculated using 7 perioperative variables including gender, ASA score, neoadjuvant treatment (NAT), biliary stent positioning, type of surgical approach (open, laparoscopic, robot-assisted), associated vascular resections, type of lesion. Perioperative characteristics and short-term postoperative outcomes were compared before and after matching.

Results: Overall, 81 (10%) patients had 80 years or more. Before matching, octogenarians had a higher rate of ASA score≥ 3 (n = 35, 43.2% vs. n = 207, 28.3%; p = 0.005) and less frequently underwent NAT (n = 11, 13.6% vs. n = 213, 29.1%; p = 0.003). Matching was successfully performed for 70 octogenarians. After matching, no differences in preoperative and intraoperative characteristics were found. Postoperatively, ICU admission was more frequent in octogenarians (50% vs 30%; p = 0.01). Although in-hospital mortality was higher in octogenarians before matching (7.4% vs 2.9% in the younger cohort; p = 0.03), no difference was noted between the matched cohorts (p = 0.36). Postoperative morbidity was comparable between groups in the whole and selected populations. At the multivariate analysis, chronological age was not recognized as a prognostic factor for cumulative major complications, while ASA ≥3 was the only confirmed influencing feature (OR 2.98; 95%CI: 1.6-6.8; p = 0.009).

Conclusio: In high-volume centers, PD in octogenarians shows similar outcomes than younger patients. Age itself should not be considered an exclusion criterion for PD, but a focused preoperative assessment is essential for adequate patient selection.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.suronc.2021.101688DOI Listing
November 2021

Robotic Extended Ultrasound-Guided Distal Pancreatectomy for Pancreatic Metastases from Uveal Melanoma.

Ann Surg Oncol 2021 Nov 27. Epub 2021 Nov 27.

USL Toscana Sud Est, Grosseto, Italy.

Background: Isolated pancreatic metastasis from melanoma is extremely uncommon and accounts for approximately only 2% of visceral disseminations of melanoma. Interestingly, pancreatic localizations disproportionately derive from primary ocular melanoma. Despite the currently available evidence on this argument being scarce, the survival outcomes of patients receiving resection for visceral melanoma metastases are reported to be superior than those managed by non-surgical modalities. CASE PRESENTATION: A 59-year-old female with a history of uveal melanoma presented with surveillance-detected metastatic disease confined to the pancreas. Computed tomography demonstrated one lesion located in the body of the pancreas and one further lesion in the head. The presented video illustrates the details of an extended, ultrasound-guided, robotic distal pancreatectomy.

Discussion: Metastatic ocular melanoma has a highly variable natural history, which ranges from a fulminant course to prolonged stable disease. In contrast to cutaneous melanoma derivation, metastases mostly occur via hematogenous spread, in the absence of lymphatic drainage of the eye. Liver is the most common site of secondary localization and is not involved by metastatic disease in <10% of cases. Interestingly, patients with extrahepatic metastases tend to have significantly better survival rates than those with hepatic disease. Fewer than 100 cases of pancreatic metastasis from malignant melanoma are reported in the medical literature, including a relatively high percentage of primary ocular malignancies. Furthermore, the prognosis of these patients is essentially unknown, although metastatic melanoma of both cutaneous and ocular origin generally indicates poor survival. Although no robust evidence is available, a number of reports suggest that pancreatic resection may improve survival in these patients. A large retrospective review investigating the association between treatment modalities and survival of patients with abdominal visceral melanoma metastases showed that patients receiving resection had a superior median survival compared with patients treated medically. Although patients with metastases of the gastrointestinal tract showed the best outcomes following surgery, patients with pancreas metastasis (of both cutaneous and ocular origin) undergoing resection also exhibited a significant survival advantage compared with those treated non-surgically. Minimally invasive pancreatectomy is gaining momentum. In fact, in selected patients there are distinct advantages compared with conventional surgery owing to reduced postoperative morbidity and earlier return to daily activities, while maintaining the oncological tenets of resection. Recent reports suggest that the application of robots may provide some advantages over conventional laparoscopy, especially for patients necessitating technically challenging surgeries. Such benefits are mainly in relation to the rate of conversion, length of postoperative hospital stay, and number of cases necessary to surmount the learning curve and reach optimal performance; however, no definitive conclusions can be drawn due to the lack of high-level evidence..
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1245/s10434-021-11116-5DOI Listing
November 2021

Quantitative assessment of the impact of COVID-19 pandemic on pancreatic surgery: an Italian multicenter analysis of 1423 cases from 10 tertiary referral centers.

Updates Surg 2021 Nov 24. Epub 2021 Nov 24.

Department of Surgery, Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli", IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy.

Few evidences are present on the consequences of coronavirus disease 2019 (COVID-19) pandemic on pancreatic surgery. Aim of this study is to evaluate how COVID-19 influenced the diagnostic and therapeutic pathways of surgical pancreatic diseases. A comparative analysis of surgical volumes and clinical, surgical and perioperative outcomes in ten Italian referral centers was conducted between the first semester 2020 and 2019. One thousand four hundred and twenty-three consecutive patients were included in the analysis: 638 from 2020 and 785 from 2019. Surgical volume in 2020 decreased by 18.7% (p < 0.0001). Benign/precursors diseases (- 43.4%; p < 0.0001) and neuroendocrine tumors (- 33.6%; p = 0.008) were the less treated diseases. No difference was reported in terms of discussed cases at the multidisciplinary tumor board (p = 0.43), mean time between diagnosis and neoadjuvant treatment (p = 0.91), indication to surgery and surgical resection (p = 0.35). Laparoscopic and robot-assisted procedures dropped by 45.4% and 61.9%, respectively, during the lockdown weeks of 2020. No difference was documented for post-operative intensive care unit accesses (p = 0.23) and post-operative mortality (p = 0.06). The surgical volume decrease in 2020 will potentially lead, in the near future, to the diagnosis of a higher rate of advanced stage diseases. However, the reassessment of the Italian Health Service kept guarantying an adequate level of care in tertiary referral centers. Clinicaltrials.gov ID: NCT04380766.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s13304-021-01171-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8611384PMC
November 2021

Robotic versus conventional laparoscopic technique for the treatment of left-sided colonic diverticular disease: a systematic review with meta-analysis.

Int J Colorectal Dis 2021 Oct 1. Epub 2021 Oct 1.

Department of General and Urgency Surgery, Misericordia Hospital, Via Senese, 161, 58100, Grosseto, Italy.

Purpose: Minimally invasive surgery has been universally accepted as a valid option for the treatment of diverticular disease, provided specific expertise is available. Over the last decade, there has been a growing interest in the application of robotic approaches for diverticular disease. We aimed at evaluating whether robotic colectomy may offer some advantages over the laparoscopic approach for surgical treatment of diverticular disease by meta-analyzing the available data from the medical literature.

Methods: The PubMed/Medline, EMBASE, and Web Of Sciences electronic databases were searched for literature up to December 2020. Inclusion criteria considered all comparative studies evaluating robotic versus laparoscopic colectomy for diverticulitis eligible. The conversion rate to the open approach was evaluated as the primary outcome.

Results: The data of 4177 patients from nine studies were included in the analysis. There were no significant differences in the baseline characteristics. Patients undergoing laparoscopic colectomy compared to those who underwent surgery with a robotic approach had a significantly higher risk of conversion into an open procedure (12.5% vs. 7.4%, p < 0.00001) and abbreviated hospital stay (p < 0.0001) at the price of a longer operating time (p < 0.00001).

Conclusion: Compared with conventional laparoscopic surgery, the robotic approach offers significant advantages in terms of conversion rate and shortened hospital stay for the treatment of diverticular disease. However, because of the lack of available evidence, it is impossible to draw definitive conclusions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00384-021-04038-xDOI Listing
October 2021

Laparoscopic Compared with Open D2 Gastrectomy on Perioperative and Long-Term, Stage-Stratified Oncological Outcomes for Gastric Cancer: A Propensity Score-Matched Analysis of the IMIGASTRIC Database.

Cancers (Basel) 2021 Sep 8;13(18). Epub 2021 Sep 8.

Department of Surgical Sciences-PhD Program in Advanced Surgical Technologies, Sapienza University of Rome, 00161 Rome, Italy.

Background: The laparoscopic approach in gastric cancer surgery is being increasingly adopted worldwide. However, studies focusing specifically on laparoscopic gastrectomy with D2 lymphadenectomy are still lacking in the literature. This retrospective study aimed to compare the short-term and long-term outcomes of laparoscopic versus open gastrectomy with D2 lymphadenectomy for gastric cancer.

Methods: The protocol-based, international IMIGASTRIC (International study group on Minimally Invasive surgery for Gastric Cancer) registry was queried to retrieve data on patients undergoing laparoscopic or open gastrectomy with D2 lymphadenectomy for gastric cancer with curative intent from January 2000 to December 2014. Eleven predefined, demographical, clinical, and pathological variables were used to conduct a 1:1 propensity score matching (PSM) analysis to investigate intraoperative and recovery outcomes, complications, pathological findings, and survival data between the two groups. Predictive factors of long-term survival were also assessed.

Results: A total of 3033 patients from 14 participating institutions were selected from the IMIGASTRIC database. After 1:1 PSM, a total of 1248 patients, 624 in the laparoscopic group and 624 in the open group, were matched and included in the final analysis. The total operative time (median 180 versus 240 min, < 0.0001) and the length of the postoperative hospital stay (median 10 versus 14.8 days, < 0.0001) were longer in the open group than in the laparoscopic group. The conversion to open rate was 1.9%. The proportion of patients with in-hospital complications was higher in the open group (21.3% versus 15.1%, = 0.004). The median number of harvested lymph nodes was higher in the laparoscopic approach (median 32 versus 28, < 0.0001), and the proportion of positive resection margins was higher ( = 0.021) in the open group (5.9%) than in the laparoscopic group (3.2%). There was no significant difference between the groups in five-year overall survival rates (77.4% laparoscopic versus 75.2% open, = 0.229).

Conclusion: The adoption of the laparoscopic approach for gastric resection with D2 lymphadenectomy shortened the length of hospital stay and reduced postoperative complications with respect to the open approach. The five-year overall survival rate after laparoscopy was comparable to that for patients who underwent open D2 resection. The types of surgical approaches are not independent predictive factors for five-year overall survival.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/cancers13184526DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8465518PMC
September 2021

Perihepatic parasitic leiomyoma.

Surgery 2021 Aug 21. Epub 2021 Aug 21.

Department of Surgery, Azienda USL Toscana Sud Est, Grosseto, Italy.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.surg.2021.07.029DOI Listing
August 2021

Review on Perioperative and Oncological Outcomes of Robotic Gastrectomy for Cancer.

J Pers Med 2021 Jul 6;11(7). Epub 2021 Jul 6.

USL Toscana Sud Est, Misericordia Hospital, 58100 Grosseto, Italy.

Background: Minimally invasive gastrectomy is currently considered a valid option to treat gastric cancer and is gaining increasing acceptance. Recent reports have suggested that the application of robots may confer some advantages over conventional laparoscopy, but the role of robotic surgery in clinical practice is still uncertain. We aimed to critically review the relevant evidence comparing robotic to standard laparoscopic surgery in performing radical gastrectomy.

Methods: The Pubmed/Medline electronic databases were searched through February 2021. Paper conference and the English language was the only restriction applied to our search strategy.

Results: According to the existing data, robotic gastrectomy seems to provide some benefits in terms of blood loss, rate of conversion, procedure-specific postoperative morbidity, and length of hospital stay. Robotic gastrectomy is also associated with a longer duration of surgery and a higher economic burden as compared to its laparoscopic counterpart. No significant differences have been disclosed in terms of long-term survivals, while the number of lymph nodes retrieved with robotic gastrectomy is generally higher than that of laparoscopy.

Conclusions: The current literature suggests that robotic radical gastrectomy appears as competent as the conventional laparoscopic procedure and may provide some clinical advantages. However, due to the relative paucity of high-level evidence, it is not possible to draw definitive conclusions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/jpm11070638DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8306865PMC
July 2021

Pure laparoscopic versus robotic liver resections: Multicentric propensity score-based analysis with stratification according to difficulty scores.

J Hepatobiliary Pancreat Sci 2021 Jul 22. Epub 2021 Jul 22.

Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, Milan, Italy.

Background: The benefits of pure laparoscopic and robot-assisted liver resections (LLR and RALR) are known in comparison to open surgery. The aim of the present retrospective comparative study is to investigate the role of RALR and LLR according to different levels of difficulty.

Methods: The institutional databases of six high-volume hepatobiliary centers were retrospectively reviewed. The study population was divided in two groups: LLR and RALR. The procedures were stratified for difficulty levels accordingly to three classifications. A propensity score matching was implemented to mitigate selection bias. Short-term outcomes were the object of comparison.

Results: Nine hundred and thirty-six LLR and 403 RALR were collected. RALR exhibited fewer cases of intraoperative blood loss, lower transfusion and conversion rates (especially for oncological radicality) than LLR in the setting of highly difficult operations, whereas LLR had lower postoperative morbidity and fewer low-grade complications. For intermediate and low-difficulty resections, the intraoperative advantages of RALR gradually decreased to nonsignificant results and LLR remained associated with lower postoperative morbidity.

Conclusion: Robot-assisted liver resections do not show operative nor clinically significant benefits over LLR for low- and intermediate-difficulty resections. By reducing conversion rates, RALR can favour the operative feasibility of difficult resections possibly extending the indications of minimally invasive approaches for liver resection.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jhbp.1022DOI Listing
July 2021

Robotic pancreatic surgery: minimally invasive approach to challenging operations.

Minerva Surg 2021 Apr;76(2):138-145

Division of Oncologic Surgery and Robotics, Department of Oncology, Careggi University Hospital, Florence, Italy.

Background: Pancreatic surgery is still associated with high perioperative morbidity and mortality. The purpose of this study was to present the short-term outcomes of robot-assisted pancreatic surgery, including pancreaticoduodenectomy (RAPD), distal pancreatectomy (RDP) with or without splenectomy, enucleation (REN), and atypical resection (RAR), for benign, borderline, and malignant lesions at a high-volume center.

Methods: A single-center, prospective database was used to retrospectively analyze the early outcomes of robotic pancreatic procedures completed between 2014 and 2020. Out of 124 attempted operations, 3 patients received palliative robotic surgery (2.4%). Of the remaining 121, 14 (11.6%) were converted to open surgery. The robotic procedures included 107 patients: 56 underwent RAPD, 31 underwent RDP (28 with and 3 without splenectomy), 16 underwent REN, and 4 underwent RAR (2 central and 2 total pancreatectomies).

Results: The preoperative baseline characteristics and comorbidities were consistent with those of a Western population. The overall incidence of complications was 43.9%, with the more severe (Clavien-Dindo III-IV) occurring after RAPD (19.6%). We collected 7 (13.1%) postoperative pancreatic fistulae after RAPD, 5 (16.1%) after RADP, and 2 (12.5%) after REN. The two central pancreatectomies developed a biochemical leak without sequelae. Three patients (2.8%) died within 90 days after surgery. Early refeeding was achieved in those who did not experience severe complications, while the median hospital stay was 8 days. The median number of harvested lymph nodes was 22, with non-R1 microscopic residual tumors found.

Conclusions: Robotic pancreatic surgery is a safe and oncologically adequate technique to manage benign and malignant diseases arising from the head, body, and tail of the pancreas.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.23736/S2724-5691.21.08435-2DOI Listing
April 2021

Robotic esophagectomy: results from a tertiary care Italian center.

Updates Surg 2021 Jun 16;73(3):839-845. Epub 2021 Apr 16.

USL Toscana Sud Est, Grosseto, Italy.

There is growing evidence supporting the use of minimally invasive resection in esophageal surgery, mainly due to reduced postoperative morbidity and faster recovery after surgery. In recent years, robot-assisted surgery has shown some potential benefits over conventional laparo-thoracoscopic esophagectomy. The purpose of this study is to report our experience with different esophageal resections with a full-robotic approach for malignant disease. All consecutive patients with resectable esophageal malignancy undergoing robotic esophagectomy over a 6-year time frame by a single surgical team were included in this analysis. Perioperative and clinicopathological outcomes were assessed. A total of 76 patients received robotic esophagectomy. Surgeries included 45 Lewis procedures, 25 McKeown procedures, and six transhiatal resections. There were no intraoperative complications and no conversions occurred. The rate of postoperative morbidity was 41%, while the rate of anastomotic leak was 13%. Overall, eight patients required reintervention. All patients received R0 resection, with a median of harvested lymph nodes of 35. 30-day and 90-day mortality was 3.9 and 7.9%, respectively. Our findings support the safety and oncological efficiency of full-robotic esophagectomy. All procedures of esophageal resection were associated with the expected perioperative morbidity while providing excellent pathological outcomes for patients with malignancy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s13304-021-01050-2DOI Listing
June 2021

Robotic Versus Open Liver Resection in Hepatocarcinoma: Surgical and Oncological Outcomes.

Surg Laparosc Endosc Percutan Tech 2021 Jan 21;31(4):468-474. Epub 2021 Jan 21.

Division of Oncological and Robotic General Surgery, Careggi University Hospital.

Background: Minimally invasive approaches are spreading in every field of surgery, including liver surgery. However, studies comparing robotic hepatectomy with the conventional open approach regarding oncologic outcomes for hepatocellular carcinoma are limited.

Materials And Methods: We retrospectively reviewed demographics characteristics, pathologic features, surgical, and oncological outcomes of patients who underwent robotic and conventional open liver resection for hepatocellular carcinoma.

Results: No significant differences in demographics features, tumor size, tumor location, and type of liver resection were found. The morbidity rate was similar, 23% for the open group versus 17% of the robotic group (P=0.605). Perioperative data analysis showed a greater estimated blood loss in patients who underwent open resection, if compared with robotic group (P=0.003). R0 resection and disease-free resection margins showed no statistically significant differences. The 3-year disease-free survival of the robotic group was comparable with that of the open group (54% vs. 37%; P=0.592), as was the 3-year overall survival (87% vs. 78%; P=0.203).

Conclusions: The surgical and the oncological outcomes seem to be comparable between minimally invasive and open hepatectomy. Robotic liver resections are effective, and do not compromise the oncological outcome, representing a reasonable alternative to the open approach.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLE.0000000000000904DOI Listing
January 2021

Robotic versus open pancreaticoduodenectomy: Is there any difference for frail patients?

Surg Oncol 2021 Jun 5;37:101515. Epub 2021 Jan 5.

Surgical Oncology and Robotics, Careggi University Hospital, Florence, Italy.

Background: Old age and frailty are predictors of early postoperative results after pancreatic surgery. We analysed the results of robotic and open pancreatoduodenectomy in elderly and frail patients.

Methods: Data from the local robotic pancreatoduodenectomy database were reviewed and matched with those from open operations during the same period (2014-2020). Both old age and frailty were used to determine any correlation with postoperative outcomes. Elderly patients were defined as patients aged 70 years or more, while frailty was classified according to the validated modified Frailty Index.

Results: A total of 118 pancreatoduodenectomies were included in the analysis: 65 (55.1%) robotic and 53 (44.9%) open. More than 50% of patients were frail. Overall, 7.6% of patients experienced grade IV Clavien-Dindo complications, and 3.4% died within 90 days after surgery. Frail patients experienced a similar rate of severe complications after robotic vs. open operations (5.3 vs. 11.6; p = 0.439) but earlier refeeding (3 days vs. 4 days; p = 0.006) and earlier drain removal (6 days vs. 7 days; p = 0.046) when operated on by a robotic approach. The oncological outcomes, including limphnodes retrieval, residual disease, recurrences, and survival, were not influenced by the surgical approach. Non-elderly patients also showed more benefits with the robotic approach (lower complication index, earlier refeeding, and drain removal).

Conclusions: Robotic pancreatoduodenectomy is associated with risks of major complications that are comparable to those of open operation in frail patients. Some perioperative parameters (refeeding, drain removal) seem to favour robotics in frail patients and younger patients, although at the price of longer operating times.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.suronc.2020.12.009DOI Listing
June 2021

Robotic vs open distal pancreatectomy: A multi-institutional matched comparison analysis.

J Hepatobiliary Pancreat Sci 2020 Dec 12. Epub 2020 Dec 12.

Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy.

Background: Pancreatic surgery is still a challenge even in high-volume centers. Clinically relevant postoperative pancreatic fistula (CR-POPF) represents the greatest contributor to major morbidity and mortality, especially following pancreatic distal resection. In this study, we compared robotic distal pancreatectomy (RDP) to open distal pancreatectomy (ODP) in terms of CR-POPF development and analyzed oncologic efficacy of RDP in the subgroup of patients with pancreatic ductal adenocarcinoma (PDAC).

Methods: We collected data from five high-volume centers for pancreatic surgery and performed a matched comparison analysis to compare short and long-term outcomes after ODP or RDP. Patients were matched with a 2:1 ratio according to age, ASA (American Society of Anesthesiologists) score, body mass index (BMI), final pathology, and TNM (Tumour, Node, Metastasis) staging system VIII ed.

Results: Two hundred and forty-six patients who underwent 82 RDPs and 164 ODPs were included. No differences were found in the incidence of CR-POPF. In the PDAC group, median DFS and OS were 10.8 months and 14.8 months in the ODP group and 10.4 months and 15 months in the RDP group, respectively.

Conclusions: Robotic distal pancreatectomy is a safe surgical strategy for PDAC and incidence of CR-POPF is equivalent between RDP and ODP. RDP should be considered equivalent to ODP in terms of oncological efficacy when performed in high-volume and proficient centers.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jhbp.881DOI Listing
December 2020

Average treatment effect of robotic versus laparoscopic rectal surgery for rectal cancer.

Int J Med Robot 2021 Apr 28;17(2):e2210. Epub 2020 Dec 28.

Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy.

Background: The aim of this study is to estimate what would have happened if all patients treated with laparoscopy for rectal cancer had instead been treated with the robotic technique.

Methods: To estimate the average treatment effect (ATE) of the robotic technique over the laparoscopic approach, data from patients treated at two centres between 2007 and 2018 were used to obtain counterfactual outcomes using an inverse probability weighting (IPW) adjustment.

Results: This study enrolled 261 patients, of which 177 and 84 patients had undergone robotic surgery and standard laparoscopy, respectively. After IPW adjustment, the difference between the groups was similar in the pseudo-population. The average conversion rate would fall by an estimated 6.1% if all procedures had been robotic (p = 0.045). All other post-operative variables showed no differences regardless of the approach.

Conclusion: ATE estimation suggests that robotic rectal cancer surgery could be associated with a lower conversion rate. The approach did not affect the post-operative morbidity rates or the operative time.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/rcs.2210DOI Listing
April 2021

Impact of COVID-19 outbreak on esophageal cancer surgery in Northern Italy: lessons learned from a multicentric snapshot.

Dis Esophagus 2021 Jun;34(6)

General, Esophageal and Gastric Surgery Unit, University Hospital of Verona, Verona, Italy.

Coronavirus Disease-19 (COVID-19) outbreak has significantly burdened healthcare systems worldwide, leading to reorganization of healthcare services and reallocation of resources. The Italian Society for Study of Esophageal Diseases (SISME) conducted a national survey to evaluate changes in esophageal cancer management in a region severely struck by COVID-19 pandemic. A web-based questionnaire (26 items) was sent to 12 SISME units. Short-term outcomes of esophageal resections performed during the lockdown were compared with those achieved in the same period of 2019. Six (50%) centers had significant restrictions in their activity. However, overall number of resections did not decrease compared to 2019, while a higher rate of open esophageal resections was observed (40 vs. 21.7%; P = 0.034). Surgery was delayed in 24 (36.9%) patients in 6 (50%) centers, mostly due to shortage of anesthesiologists, and occupation of intensive care unit beds from intubated COVID-19 patients. Indications for neoadjuvant chemo (radio) therapy were extended in 14% of patients. Separate COVID-19 hospital pathways were active in 11 (91.7%) units. COVID-19 screening protocols included nasopharyngeal swab in 91.7%, chest computed tomography scan in 8.3% and selective use of lung ultrasound in 75% of units. Postoperative interstitial pneumonia occurred in 1 (1.5%) patient. Recovery from COVID-19 pandemic was characterized by screening of patients in all units, and follow-up outpatient visits in only 33% of units. This survey shows that clinical strategies differed considerably among the 12 SISME centers. Evidence-based guidelines are needed to support the surgical esophageal community and to standardize clinical practice in case of further pandemics.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/dote/doaa124DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7717178PMC
June 2021

Emergency surgery in the time of Coronavirus: the pandemic effect.

Minerva Surg 2021 Aug 11;76(4):382-387. Epub 2020 Nov 11.

Unit of Emergency Surgery, Careggi University Hospital, Florence, Italy.

Background: The COVID-19 epidemic became a challenge for Emergency Departments (ED) and a remarkable reduction in surgical emergencies has been widely noticed. The aim of the present study was to evaluate the impact of the pandemic period in the need of surgical emergencies.

Methods: Between January 1, and May 31, 2020 all the consecutive general surgery emergencies performed by the Unit Hospital Emergency Surgery of the Careggi University (Florence, Italy) were prospectively recorded and compared to the same period of 2019. Demographic and clinical data were recorded and analyzed.

Results: The number of surgical procedures decreased only in the month of March 2020 (compared to 2019), while in April the total numer of emergency surgical procedures was similar. Only appendectomy, complicated hernia repair and colonic resection were significantly reduced (40%, 48% and 33% respectively). The number of small intestine excision, cholecystectomy and lysis of peritoneal adhesions remained stable throughout the entire period. No statistically significant differences were found considering age, sex, Emergency Surgery Score, mortality, ICU postoperative admission and time between admission and surgery, even when analyzed with multivariate analysis for every single surgical procedure, suggesting a comparable disease severity and comorbility patterns. Mortality in COVID patients was 25%, compared to 7% of no-covid patients.

Conclusions: The COVID-19 pandemic has caused major changes in daily clinical practice, especially in areas such as Emergency. This has led to a temporary reduction and changes in the flow of patients to the emergency room, with implications also for emergency surgical activities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.23736/S0026-4733.20.08545-4DOI Listing
August 2021

Robotic enucleation for oesophageal benign and borderline tumours: Less is more?

Int J Med Robot 2021 Feb 12;17(1):1-7. Epub 2020 Oct 12.

Division of Surgical Oncology and Robotics, Department of Oncology, Careggi University Hospital, Florence, Italy.

Background: Oesophageal benign to borderline tumours are rare entities, and their optimal treatment strategy remains controversial. Surgical robotic enucleation is an option to optimize their management.

Methods: We prospectively collected data on seven consecutive oesophageal benign to borderline tumours operated robotically over a 4-year period. Patient baseline characteristics, perioperative outcomes and medium-term follow-ups were reviewed and analysed retrospectively.

Results: Two patients underwent a robotic oesophagectomy and five underwent a simple enucleation. These last were the objective of the final analysis. Median operative time was 150 min. Neither deaths nor postoperative complications occurred. Median oral feeding started on postoperative day 3.5. The median postoperative stay was 5 days. Final histopathology confirmed two gastrointestinal stromal tumours, two leiomyomas and one simple cyst.

Conclusions: Robotic enucleation of oesophageal benign to borderline tumours is a feasible procedure in a dedicated oesophageal unit, with optimal perioperative outcomes in a small series of cases with limited follow-up.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/rcs.2178DOI Listing
February 2021

Emergency surgery for appendectomy and incidental diagnosis of superficial peritoneal endometriosis in fertile age women.

Reprod Biomed Online 2020 Oct 20;41(4):729-733. Epub 2020 Jun 20.

Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Obstetrics and Gynecology, Careggi University Hospital Florence, Italy. Electronic address:

Research Question: This study aimed to evaluate the presence of superficial peritoneal endometriosis (SUP) in women referred to emergency surgery for right iliac fossa (RIF) pain and undergoing an appendectomy, considering which factors may be useful to suspect and identify endometriosis.

Design: An observational case-control study was conducted on a group (n = 149) of fertile age women. After surgery, Group A was selected upon the diagnosis of endometriosis (n = 34); Group B (n = 115) represented the controls. Demographics, comorbidities and clinical findings were registered and analysed.

Results: Appendicitis of various grades of severity was diagnosed in all patients, but SUP was also identified in 23%, of which 14.7% also presented with endometriosis of the appendix. Women in Group A reported chronic pelvic pain, dysmenorrhoea, dyspareunia and oral contraceptive use more frequently. At multivariate analysis, factors associated with endometriosis were: age <40 years, autoimmune disorders, multiple allergies, abdominal chronic pain, associated gynaecological pain symptoms, Alvarado score ≤6, and inconclusive ultrasound findings.

Conclusions: The incidental finding of SUP in fertile age women presenting with an acute RIF pain and undergoing emergency surgery is a relevant observation. Clinical history and symptoms should guide surgeons in performing a correct diagnosis and in referring the patient to the gynaecology specialist.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.rbmo.2020.06.008DOI Listing
October 2020

Expression levels of circulating miRNAs as biomarkers during multimodal treatment of rectal cancer - TiMiSNAR-mirna: a substudy of the TiMiSNAR Trial (NCT03962088).

Trials 2020 Jul 25;21(1):678. Epub 2020 Jul 25.

Department of Oncology, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy.

Background: Neoadjuvant chemoradiotherapy followed by surgery is the mainstay treatment for locally advanced rectal cancer, leading to significant decrease in tumor size (downsizing) and a shift towards earlier disease stage (downstaging). Extensive histopathological work-up of the tumor specimen after surgery including tumor regression grading and lymph node status helped to visualize individual tumor sensitivity to chemoradiotherapy, retrospectively. As the response to neoadjuvant chemoradiotherapy is heterogeneous, however, valid biomarkers are needed to monitor tumor response. A relevant number of studies aimed to identify molecular markers retrieved from tumor tissue while the relevance of blood-based biomarkers is less stringent assessed. MicroRNAs are currently under investigation to serve as blood-based biomarkers. To date, no screening approach to identify relevant miRNAs as biomarkers in blood of patients with rectal cancer was undertaken. The aim of the study is to investigate the role of circulating miRNAs as biomarkers in those patients included in the TiMiSNAR Trial (NCT03465982). This is a biomolecular substudy of TiMiSNAR Trial (NCT03962088).

Methods: All included patients in the TiMiSNAR Trial are supposed to undergo blood collection at the time of diagnosis, after neoadjuvant treatment, after 1 month from surgery, and after adjuvant chemotherapy whenever indicated.

Discussion: TiMiSNAR-MIRNA will evaluate the association of variation between preneoadjuvant and postneoadjuvant expression levels of miRNA with pathological complete response. Moreover, the study will evaluate the role of liquid biopsies in the monitoring of treatment, correlate changes in expression levels of miRNA following complete surgical resection with disease-free survival, and evaluate the relation between changes in miRNA during surveillance and tumor relapse.

Trial Registration: Clinicaltrials.gov NCT03962088 . Registered on 23 May 2019.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13063-020-04568-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7382047PMC
July 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s13304-020-00808-4DOI Listing
June 2020

Obstructive left side colon cancer: time for a tailored operative approach?

Minerva Chir 2020 Aug 26;75(4):244-254. Epub 2020 May 26.

Unit of Emergency Surgery, Department of Emergency, Careggi University Hospital, Florence, Italy.

Background: Colorectal cancer (CRC) obstruction is frequent but doubts remain on the best treatment. The aim of this study is to analyze the different operative approach used for CRC treatment and evaluate the outcomes for the different cases.

Methods: Patients were collected from January 2014 to December 2019 and divided in four groups: two "P" groups, namely the Hartmann's procedure (PH) group and the primary anastomosis (PA) group, and two "S" groups, namely the deviating stoma (SD) group and the self-expanding metallic stent (SS) group. The main endpoints were the quality of life and the oncologic safety.

Results: One hundred and eight patients were enrolled. The mean follow-up time was 39 months. The stomas were performed less frequently in SS but lasted more in that group. Only 45% underwent reversal surgery. Cumulative operating time was greater in S versus P groups. The rate of major complications was similar. PA had greater overall survival and disease-free survival rates than PH.

Conclusions: The various options of treatment should have different indications: primary anastomosis in stable patients, Hartmann in critical cases, SEMS for palliative intent and stoma when neo-adjuvant therapy is needed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.23736/S0026-4733.20.08299-1DOI Listing
August 2020

Correction to: Single-centre comparison of robotic and open pancreatoduodenectomy: a propensity score-matched study.

Surg Endosc 2020 Dec;34(12):5413

Surgical Oncology and Robotics, Careggi University Hospital, Florence, Italy.

In the Abstract, in the Methods section the sentence "Of the 121 included patients, 78 underwent RAPD and 43 underwent OPD." Should read: Of the 121 included patients, 77 underwent OPD and 44 underwent RAPD."
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-020-07391-0DOI Listing
December 2020

Single-centre comparison of robotic and open pancreatoduodenectomy: a propensity score-matched study.

Surg Endosc 2020 12 13;34(12):5402-5412. Epub 2020 Jan 13.

Surgical Oncology and Robotics, Careggi University Hospital, Florence, Italy.

Background: Pancreatoduodenectomy for pancreatic head and periampullary cancers is still associated with high perioperative morbidity and mortality. The aim of this study was to compare the short-term outcomes of robot-assisted pancreatoduodenectomy (RAPD) and open pancreatoduodenectomy (OPD) performed in a high-volume centre.

Methods: A single-centre, prospective database was used to retrospectively compare the early outcomes of RAPD procedures to standard OPD procedures completed between January 2014 and December 2018. Of the 121 included patients, 78 underwent RAPD and 43 underwent OPD. After propensity score matching (PSM), 35 RAPD patients were matched with 35 OPD patients with similar preoperative characteristics.

Results: There were no statistically significant differences in most of the baseline demographics and perioperative outcomes in the two groups after PSM optimization with the exception of the operative time (530 min (RAPD) versus 335 min (OPD) post-match, p < 0.000). No differences were found between the two groups in terms of complications (including pancreatic leaks, 11.4% in both OPD and RAPD), perioperative mortality, reoperations or readmissions. Earlier refeeding was obtained in the RAPD group vs. the OPD group (3 vs. 4 days, p = 0.002). Although the differences in the length of the hospital stay and blood transfusions were not statistically significant, both parameters showed a positive trend in favour of RAPD. The number of harvested lymph nodes was similar and oncologically adequate.

Conclusions: RAPD is a safe and oncologically adequate technique to treat malignancies arising from the pancreatic head and periampullary region. Several perioperative parameters resulted in trends favouring RAPD over OPD, at the price of longer operating time. Data should be reinforced with a larger sample to guarantee statistical significance.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-019-07335-3DOI Listing
December 2020

Standard (8 weeks) vs long (12 weeks) timing to minimally-invasive surgery after NeoAdjuvant Chemoradiotherapy for rectal cancer: a multicenter randomized controlled parallel group trial (TiMiSNAR).

BMC Cancer 2019 12 16;19(1):1215. Epub 2019 Dec 16.

Ospedale G.B. Morgagni L. Pierantoni, Forlì, Italy.

Background: The optimal timing of surgery in relation to chemoradiation is still controversial. Retrospective analysis has demonstrated in the recent decades that the regression of adenocarcinoma can be slow and not complete until after several months. More recently, increasing pathologic Complete Response rates have been demonstrated to be correlated with longer time interval. The purpose of the trial is to demonstrate if delayed timing of surgery after neoadjuvant chemoradiotherapy actually affects pathologic Complete Response and reflects on disease-free survival and overall survival rather than standard timing.

Methods: The trial is a multicenter, prospective, randomized controlled, unblinded, parallel-group trial comparing standard and delayed surgery after neoadjuvant chemoradiotherapy for the curative treatment of rectal cancer. Three-hundred and forty patients will be randomized on an equal basis to either robotic-assisted/standard laparoscopic rectal cancer surgery after 8 weeks or robotic-assisted/standard laparoscopic rectal cancer surgery after 12 weeks.

Discussion: To date, it is well-know that pathologic Complete Response is associated with excellent prognosis and an overall survival of 90%. In the Lyon trial the rate of pCR or near pathologic Complete Response increased from 10.3 to 26% and in retrospective studies the increase rate was about 23-30%. These results may be explained on the relationship between radiation therapy and tumor regression: DNA damage occurs during irradiation, but cellular lysis occurs within the next weeks. Study results, whether confirmed that performing surgery after 12 weeks from neoadjuvant treatment is advantageous from a technical and oncological point of view, may change the current pathway of the treatment in those patient suffering from rectal cancer.

Trial Registration: ClinicalTrials.gov NCT3465982.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12885-019-6271-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6912945PMC
December 2019

The use of intra-abdominal drain in minimally invasive right colectomy: a propensity score matched analysis on postoperative outcomes.

Int J Colorectal Dis 2019 Dec 14;34(12):2137-2141. Epub 2019 Nov 14.

General and Oncologic Surgery, Morgagni-Pierantoni Hospital, Ausl Romagna, Forlì, Italy.

Purpose: No evidences supporting or not the use of intra-abdominal drain (AD) in minimally invasive right colectomies have been published. This study aims to assess the outcomes on its use after robotic or laparoscopic right colectomies.

Methods: This is a multicenter propensity score matched study including patients who underwent minimally invasive right colectomy with (AD group) or without (no-AD group) the use of AD between February 1, 2007, and January 31, 2018. AD patients were matched to no-AD patients in a 1:1 ratio. Main outcomes were postoperative morbidity and mortality and anastomotic leak.

Results: A total of 653 patients were included. Of 149 (22.8%) no-AD patients, 124 could be matched. The rate of postoperative complications (AD n = 26, 21% vs. no-AD n = 26, 21%; p = 1.000), mortality (AD n = 2, 1.6% vs. no-AD n = 1, 0.8%; p = 1.000), anastomotic leak (AD n = 2, 1.6% vs. no-AD n = 5, 4.0%; p = 0.453), and wound infection (AD n = 9, 7.3% vs. no-AD n = 6, 4.8%; p = 0.581) did not significantly differ between the groups. Time to oral feeding was significantly shorter in the no-AD group [2 (1-3) vs. 3 (2-3), p = 0.0001]. The median length of hospital stay was 8 (IQR 7-9) in the AD group while it was 6 (IQR 5-9) in the no-AD group (p = 0.010).

Conclusions: In conclusion, the use of AD after minimally invasive right colectomies has no influence on postoperative morbidity and mortality rates.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00384-019-03440-wDOI Listing
December 2019

Association Between Compliance to an Enhanced Recovery Protocol and Outcome After Elective Surgery for Gastric Cancer. Results from a Western Population-Based Prospective Multicenter Study.

World J Surg 2019 10;43(10):2490-2498

General and Esophagogastric Surgery, University of Verona, Verona, Italy.

Background: The association between compliance to an enhanced recovery protocol (ERAS) and outcome after surgery for gastric cancer has been poorly investigated, particularly in Western patients. The aim of the study was to evaluate whether the rate of adherence to the ERAS program was correlated with outcome and time of discharge.

Methods: A prospective, observational, multicenter study was designed to be performed at Italian referral centers for gastric surgery. The protocol was discussed and approved by the Italian Research Group on Gastric Cancer. Twenty-three ERAS domains were applied. A multivariate logistic regression was used to assess the association between ERAS compliance and overall and major complication rates. The Poisson regression model (measured as mean ratios) was used to assess the association of ERAS compliance rate and length of stay (LOS).

Results: Eight centers participated and 290 subjects with a median age of 73 years were enrolled. The overall rates of adherence to pre-, intra-, and postoperative ERAS items were 69.8%, 60.3%, and 82.5%, respectively. At the multivariate model, there was an association between overall rate of morbidity and an overall ERAS compliance rate greater than 70% (OR 0.413; 95% CI 0.235-0.7240; P 0.002). A similar association was found for major complications (OR 0.328; 95% CI 0.151-0.709; P 0.005). The Poisson regression showed that in patients with ERAS compliance rate >70%, LOS was reduced of approximately 20% (mean ratio 0.812; 95% CI 0.694-0.950; P 0.009).

Conclusions: These results suggest a moderate compliance to an ERAS program and a significant association between adherence and outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00268-019-05068-xDOI Listing
October 2019

Not just minor resections: robotic approach for cystic echinococcosis of the liver.

Infection 2019 Dec 24;47(6):973-979. Epub 2019 Jun 24.

Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Via del Pozzo 71, 41124, Modena, MO, Italy.

Introduction: Human echinococcosis is among the 17 neglected tropical diseases recognized by the World Health Organization. It is responsible for over $3 billion of health costs every year being endemic in large areas worldwide, and liver is affected in 70% of the cases. Surgery associated to medical treatment is the gold standard and robotic approach may be a valuable tool to achieve safe, parenchyma sparing resections.

Methods: We retrospectively analyzed the outcomes of patients that underwent robotic radical surgical treatment for hydatid liver disease, from prospectively maintained databases of three Italian centers.

Results: 15 patients were included in this study, median age 51 years (24-76). 1 right hepatectomy, 2 left lateral sectionectomies, 5 segmentectomies (including 1 caudatectomy), 3 wedge resections and 5 cyst-pericystectomies were performed. Median estimated blood loss was of 100 ml (50-550 ml), and median operative time including docking was 210 min (95-590 min), with no need for conversion to open. Median hospital stay was 4 days, with only one readmission for fever. Only one patient experienced recurrence in a different liver segment.

Conclusions: In our experience, robotic approach for cystic echinococcosis of the liver proved to be a safe and effective strategy also in the so-called "difficult segments", with short post-operative stay and quick return to daily activities, along with the absence of surgical site recurrences. To the best of our knowledge, this is the largest report of robotic approach to hydatid liver disease.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s15010-019-01333-2DOI Listing
December 2019

Surgical and oncological outcomes after ultrasound-guided robotic liver resections for malignant tumor. Analysis of a prospective database.

Int J Med Robot 2019 Aug 27;15(4):e2002. Epub 2019 May 27.

Division of Oncological and Robotic General Surgery, Careggi University Hospital, Florence, Italy.

Aim: Robotic surgery is thought to have a role in widening the application of minimally invasive liver surgery. Nonetheless, data concerning surgical results for liver malignancies are presently still lacking. We aimed to evaluate the surgical and oncological outcomes of ultrasound guided robotic liver resections for hepatic malignancies.

Methods: All consecutive patients who received robotic resection of primary and secondary liver malignancies from September 2008 to January 2017 were analyzed. The same surgical team performed all procedures following the principle of parenchymal-sparing surgery.

Results: From a total of 51 patients, 13 patients (25%) underwent major and 38 (75%) minor hepatectomy. No mortality occurred. Two procedures were converted to open surgery. Five patients experienced major complications, with a reintervention rate of 6%. Median hospital stay was 5 days.

Conclusions: Robotic surgery is a safe and feasible procedure for liver resection even when dealing with malignancies. Our data show that robotic surgery can be considered a valid option to treat patients with liver malignancies in a minimally invasive manner, without compromise the oncological results.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/rcs.2002DOI Listing
August 2019
-->