Publications by authors named "Giammauro Berardi"

61 Publications

Glissonean approach for hepatic inflow control in minimally invasive anatomic liver resection: A systematic review.

J Hepatobiliary Pancreat Sci 2021 Feb 2. Epub 2021 Feb 2.

Center for Advanced Treatment of Hepatobiliary and Pancreatic Diseases, Ageo Central General Hospital, Saitama, Japan.

Background: The Glissonean approach has been widely validated for both open and minimally invasive anatomic liver resection (MIALR). However, the possible advantages compared to the conventional hilar approach are still under debate. The aim of this systematic review was to evaluate the application of the Glissonean approach in MIALR.

Methods: A systematic review of the literature was conducted on PubMed and Ichushi databases. Articles written in English or Japanese were included. From 2,390 English manuscripts evaluated by title and abstract, 43 were included. Additionally, 23 out of 463 Japanese manuscripts were selected. Duplicates were removed, including the most recent manuscript.

Results: The Glissonean approach is reported for both major and minor MIALR. The 1st, 2nd and 3rd order divisions of both right and left portal pedicles can be reached following defined anatomical landmarks. Compared to the conventional hilar approach, the Glissonean approach is associated with shorter operative time, lower blood loss, and better peri-operative outcomes.

Conclusions: Glissonean approach is safe and feasible for MIALR with several reported advantages compared to the conventional hilar approach. Clear knowledge of Laennec's capsule anatomy is necessary and serves as a guide for the dissection. However, the best surgical approach to be performed depends on surgeon experience and patients' characteristics. Standardization of the Glissonean approach for MIALR is important.
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http://dx.doi.org/10.1002/jhbp.908DOI Listing
February 2021

Laparoscopic versus open rectal resection: a 1:2 propensity score-matched analysis of oncological adequateness, short- and long-term outcomes.

Int J Colorectal Dis 2021 Jan 22. Epub 2021 Jan 22.

Department of Medical Surgical Science and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Via di Grottarossa 1035-39, 00189, Rome, Italy.

Background: Laparoscopic resections for rectal cancer are routinely performed in high-volume centres. Despite short-term advantages have been demonstrated, the oncological outcomes are still debated. The aim of this study was to compare the oncological adequateness of the surgical specimen and the long-term outcomes between open (ORR) and laparoscopic (LRR) rectal resections.

Methods: Patients undergoing laparoscopic or open rectal resections from January 1, 2013, to December 31, 2019, were enrolled. A 1:2 propensity score matching was performed according to age, sex, BMI, ASA score, comorbidities, distance from the anal verge, and clinical T and N stage.

Results: Ninety-eight ORR were matched to 50 LRR. No differences were observed in terms of operative time (224.9 min. vs. 230.7; p = 0.567) and postoperative morbidity (18.6% vs. 20.8%; p = 0.744). LRR group had a significantly earlier soft oral intake (p < 0.001), first bowel movement (p < 0.001), and shorter hospital stay (p < 0.001). Oncological adequateness was achieved in 85 (86.7%) open and 44 (88.0%) laparoscopic resections (p = 0.772). Clearance of the distal (99.0% vs. 100%; p = 0.474) and radial margins (91.8 vs. 90.0%, p = 0.709), and mesorectal integrity (94.9% vs. 98.0%, p = 0.365) were comparable between groups. No differences in local recurrence (6.1% vs.4.0%, p = 0.589), 3-year overall survival (82.9% vs. 91.4%, p = 0.276), and disease-free survival (73.1% vs. 74.3%, p = 0.817) were observed.

Conclusions: LRR is associated with good postoperative results, safe oncological adequateness of the surgical specimen, and comparable survivals to open surgery.
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http://dx.doi.org/10.1007/s00384-021-03841-wDOI Listing
January 2021

Landmarks and techniques to perform minimally invasive liver surgery: A systematic review with a focus on hepatic outflow.

J Hepatobiliary Pancreat Sci 2021 Jan 21. Epub 2021 Jan 21.

Center for Advanced Treatment of Hepatobiliary and Pancreatic Diseases, Ageo Central General Hospital, Saitama, Japan.

Purpose: In this systematic review, we aimed to clarify the useful anatomic structures and assess available surgical techniques and strategies required to safely perform minimally invasive anatomic liver resection (MIALR), with a particular focus on the hepatic veins (HVs).

Methods: A systematic review was conducted using MEDLINE/PubMed for English articles and Ichushi databases for Japanese articles through September 2020. The quality assessment of the articles was performed in accordance with the Scottish Intercollegiate Guidelines Network (SIGN).

Results: A total of 3372 studies were obtained, and 59 were selected and reviewed. Due to the limited number of published comparative studies and case series, the degree of evidence from our review was low. Thirty-two articles examined the anatomic landmarks and crucial structures for approaching HVs. Regarding the direction of HV exposure, 32 articles focused on the techniques and advantages of exposing HVs from either the root or the periphery. Ten articles focused on the techniques to perform a segmentectomy 8 in particularly difficult cases of MIALR. In seven articles, bleeding control from HVs was also discussed.

Conclusions: This review may help experts reach a consensus regarding the best approach to the management of hepatic veins during MIALR.
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http://dx.doi.org/10.1002/jhbp.898DOI Listing
January 2021

Graft Retrieval for Liver Transplant in a Donor With Giant Thoracoabdominal Aortic Aneurysm.

Exp Clin Transplant 2021 02 11;19(2):160-162. Epub 2021 Jan 11.

From the Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy.

Liver transplant is a lifesaving treatment option for end-stage liver disease in those with or without hepatocellular carcinoma. Organ shortage is currently the main limitation to liver transplant in many countries worldwide, with fewer donors than patients waiting for transplant. Different solutions have been proposed, including the use of marginal grafts, living donors, and machine perfusion. Potential organs are sometimes discarded due to technical difficulties that may hamper the success of their retrieval and eventual transplant. Here, we present the case of a 69-year-old man with a history of cardiac and pulmonary disease who was considered a potential organ donor after brain death. According to the patient's history, a computed tomography before acceptance was required. The scan revealed a giant thoracoabdominal aortic aneurysm. The donor had previous cardiac surgery with sternotomy and a talcage of the right pleural space. The 2 renal arteries were also unusable because of spread calcifications and involvement by the aneurism. We decided to cannulate the superior mesenteric vessels. Liver transplant was uneventful, and the recipient had no vascular complications, as shown by Doppler ultrasonography performed on days 1, 3, and 7. Length of hospitalization was 14 days. Organ shortages for transplant seemed to have worsened during the COVID-19 period. Nonetheless, the condition of oncology patients can worsen if surgical treatments are delayed. Rearrangements of resources require adaptations in clinical practice.
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http://dx.doi.org/10.6002/ect.2020.0311DOI Listing
February 2021

Expert Consensus Guidelines on Minimally Invasive Donor Hepatectomy for Living Donor Liver Transplantation From Innovation to Implementation: A Joint Initiative From the International Laparoscopic Liver Society (ILLS) and the Asian-Pacific Hepato-Pancreato-Biliary Association (A-PHPBA).

Ann Surg 2021 01;273(1):96-108

Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea.

Objective: The Expert Consensus Guidelines initiative on MIDH for LDLT was organized with the goal of safe implementation and development of these complex techniques with donor safety as the main priority.

Background: Following the development of minimally invasive liver surgery, techniques of MIDH were developed with the aim of reducing the short- and long-term consequences of the procedure on liver donors. These techniques, although increasingly performed, lack clinical guidelines.

Methods: A group of 12 international MIDH experts, 1 research coordinator, and 8 junior faculty was assembled. Comprehensive literature search was made and studies classified using the SIGN method. Based on literature review and experts opinions, tentative recommendations were made by experts subgroups and submitted to the whole experts group using on-line Delphi Rounds with the goal of obtaining >90% Consensus. Pre-conference meeting formulated final recommendations that were presented during the plenary conference held in Seoul on September 7, 2019 in front of a Validation Committee composed of LDLT experts not practicing MIDH and an international audience.

Results: Eighteen Clinical Questions were addressed resulting in 44 recommendations. All recommendations reached at least a 90% consensus among experts and were afterward endorsed by the validation committee.

Conclusions: The Expert Consensus on MIDH has produced a set of clinical guidelines based on available evidence and clinical expertise. These guidelines are presented for a safe implementation and development of MIDH in LDLT Centers with the goal of optimizing donor safety, donor care, and recipient outcomes.
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http://dx.doi.org/10.1097/SLA.0000000000004475DOI Listing
January 2021

The impact of robotics in liver surgery: A worldwide systematic review and short-term outcomes meta-analysis on 2,728 cases.

J Hepatobiliary Pancreat Sci 2020 Nov 17. Epub 2020 Nov 17.

Center for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Saitama, Japan.

Background: The dissemination of robotic liver surgery is slow-paced and must face the obstacle of demonstrating advantages over open and laparoscopic (LLS) approaches. Our objective was to show the current position of robotic liver surgery (RLS) worldwide and to identify if improved short-term outcomes are observed, including secondary meta-analyses for type of resection, etiology, and cost analysis.

Methods: A PRISMA-based systematic review was performed to identify manuscripts comparing RLS vs open or LLS approaches. Quality analysis was performed using the Newcatle-Ottawa score. Statistical analysis was performed after heterogeneity test and fixed- or random-effect models were chosen accordingly.

Results: After removing duplications, 2728 RLS cases were identified from the final set of 150 manuscripts. More than 75% of the cases have been performed on malignancies. Meta-analysis from the 38 comparative reports showed that RLS may offer improved short-term outcomes compared to open procedures in most of the variables screened. Compared to LLS, some advantages may be observed in favour of RLS for major resections in terms of operative time, hospital stay and rate of complications. Cost analyses showed an increased cost per procedure of around US$5000.

Conclusions: The advantages of RLS still need to be demonstrated although early results are promising. Advantages vs open approach are demonstrated. Compared to laparoscopic surgery, minor perioperative advantages may be observed for major resections although cost analyses are still unfavorable to the robotic approach.
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http://dx.doi.org/10.1002/jhbp.869DOI Listing
November 2020

Comment on "Development and Validation of a Nomogram to Preoperatively Estimate Post-Hepatectomy Liver Dysfunction Risk and Long-Term Survival in Patients With Hepatocellular Carcinoma": A "Minimally Invasive" Step Forward.

Ann Surg 2020 Oct 19. Epub 2020 Oct 19.

Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy and, Department of Human Structure and Repair, Ghent University, Belgium Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy and, Department of Human Structure and Repair, Ghent University, Belgium.

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http://dx.doi.org/10.1097/SLA.0000000000004411DOI Listing
October 2020

The impact of the coronavirus disease 2019 pandemic on a central Italy transplant center.

Medicine (Baltimore) 2020 Oct;99(41):e22174

POIT- INMI Spallanzani Infectious Diseases/Hepatology Unit.

Coronavirus disease 2019 (COVID-19) is challenging health care systems worldwide, raising the question of reducing the transplant program due to the shortage of intensive care unit beds and to the risk of infection in donors and recipients.We report the positive experience of a single Transplant Center in Rome, part of the National Institute for Infectious Diseases Lazzaro Spallanzani, one of the major national centers involved in the COVID-19 emergency.
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http://dx.doi.org/10.1097/MD.0000000000022174DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7544270PMC
October 2020

Association of Sarcopenia and Body Composition With Short-term Outcomes After Liver Resection for Malignant Tumors.

JAMA Surg 2020 11 18;155(11):e203336. Epub 2020 Nov 18.

Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy.

Importance: Previous retrospective studies have shown that sarcopenia substantially alters the postoperative and oncological outcomes after liver resection for malignant tumors. However, the evidence is limited to small retrospective studies with heterogeneous results and the lack of standardized measurements of sarcopenia.

Objective: To investigate the role of sarcopenia as a risk factor associated with 90-day morbidity after liver resection for malignant tumors.

Design, Setting, And Participants: This cohort study included 234 consecutive patients undergoing liver resection for malignant tumors at San Camillo Forlanini Hospital, Rome, Italy, between June 1, 2018, and December 15, 2019. Muscle mass and strength were assessed using the skeletal muscle index (SMI) on preoperative computed tomographic scans and the handgrip strength test, respectively. Patients were then divided into the following 4 groups: group A (normal muscle mass and strength), group B (reduced muscle strength), group C (reduced muscle mass), and group D (reduced muscle mass and strength).

Main Outcomes And Measures: The primary outcome of the study was 90-day morbidity. The following secondary outcomes were investigated: 90-day mortality, hospital stay, and readmission rate.

Results: Sixty-four major and 170 minor hepatectomies were performed in 234 patients (median age, 66.50 [interquartile range, 58.00-74.25] years; 158 men [67.5%]). The median SMI of the entire population was 46.22 (interquartile range, 38.60-58.20) cm/m2. The median handgrip strength was 30.80 (interquartile range, 22.30-36.90) kg. Patients in group D had a statistically significantly higher rate of 90-day morbidity than patients in the other groups (51.5% [35 of 68] vs 38.7% [29 of 75] in group C, 23.1% [3 of 13] in group B, and 6.4% [5 of 78] in group A; P < .001). Compared with patients in the other groups, those in group D had a longer hospital stay (10 days vs 8 days in group C, 9 days in group B, and 6 days in group A; P < .001), and more patients in this group were readmitted to the hospital (8.8% [6 of 68] vs 5.3% [4 of 75] in group C, 7.7% [1 of 13] in group B, and 0% [0 of 78] in group A; P = .02). Sarcopenia, portal hypertension, liver cirrhosis, and biliary reconstruction were independent risk factors associated with 90-day morbidity.

Conclusions And Relevance: Sarcopenia appears to be associated with adverse outcomes after liver resection for malignant tumors. Both muscle mass measurements on computed tomographic scans and muscle strength assessments with the handgrip strength test should be performed at the first clinical encounter to better classify patients and to minimize the risk of morbidity.
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http://dx.doi.org/10.1001/jamasurg.2020.3336DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7512123PMC
November 2020

Primary role of radioembolization as a downstaging strategy in patients with macrovascular invasion prior to liver transplantation.

Transpl Int 2020 Dec 3;33(12):1833-1834. Epub 2020 Oct 3.

Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Italy.

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http://dx.doi.org/10.1111/tri.13746DOI Listing
December 2020

Continuing our work: transplant surgery and surgical oncology in a tertiary referral COVID-19 center.

Updates Surg 2020 Jun 4;72(2):281-289. Epub 2020 Jun 4.

Department of General Surgery and Liver Transplantation Service, San Camillo Forlanini, Italian National Institute for the Infectious Diseases "L. Spallanzani", Via Giacomo Folchi 6A, Rome, Italy.

COVID-19 is rapidly spreading worldwide. Healthcare systems are struggling to properly allocate resources while ensuring cure for diseases outside of the infection. The aim of this study was to demonstrate how surgical activity was affected by the virus outbreak and show the changes in practice in a tertiary referral COVID-19 center. The official bulletins of the Italian National Institute for the Infectious Diseases "L. Spallanzani" were reviewed to retrieve the number of daily COVID-19 patients. Records of consecutive oncological and transplant procedures performed during the outbreak were reviewed. Patients with a high probability of postoperative intensive care unit (ICU) admission were considered as high risk and defined by an ASA score ≥ III and/or a Charlson Comorbidity Index (CCI) ≥ 6 and/or a Revised Cardiac Risk Index for Preoperative Risk (RCRI) ≥ 3. 72 patients were operated, including 12 (16.6%) liver and kidney transplantations. Patients had few comorbidities (26.3%), low ASA score (1.9 ± 0.5), CCI (3.7 ± 1.3), and RCRI (1.2 ± 0.6) and had overall a low risk of postoperative ICU admission. Few patients had liver cirrhosis (12.5%) or received preoperative systemic therapy (16.6%). 36 (50%) high-risk surgical procedures were performed, including major hepatectomies, pancreaticoduodenectomies, total gastrectomies, multivisceral resections, and transplantations. Despite this, only 15 patients (20.8%) were admitted to the ICU. Only oncologic cases and transplantations were performed during the COVID-19 outbreak. Careful selection of patients allowed to perform major cancer surgeries and transplantations without further stressing hospital resources, meanwhile minimizing collateral damage to patients.
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http://dx.doi.org/10.1007/s13304-020-00825-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7271142PMC
June 2020

Surgical treatment of stage IV colorectal cancer with synchronous liver metastases: A systematic review and network meta-analysis.

Eur J Surg Oncol 2020 07 6;46(7):1203-1213. Epub 2020 Mar 6.

Department of Human Structure and Repair, Faculty of Medicine, Ghent University, Belgium; Department of Surgery, Division of GI Surgery, Ghent University Hospital, Belgium; Cancer Research Institute Ghent (CRG), Ghent University, Belgium. Electronic address:

Background: The ideal treatment approach for colorectal cancer (CRC) with synchronous liver metastases (SCRLM) remains debated. We performed a network meta-analysis (NMA) comparing the 'bowel-first' approach (BFA), simultaneous resection (SIM), and the 'liver-first' approach (LFA).

Methods: A systematic search of comparative studies in CRC with SCRLM was undertaken using the Embase, PubMed, Web of Science, and CENTRAL databases. Outcome measures included postoperative complications, 30- and 90-day mortality, chemotherapy use, treatment completion rate, 3- and 5-year recurrence-free survival, and 3- and 5-year overall survival (OS). Pairwise and network meta-analysis were performed to compare strategies. Heterogeneity was assessed using the Higgins I statistic.

Results: One prospective and 43 retrospective studies reporting on 10 848 patients were included. Patients undergoing the LFA were more likely to have rectal primaries and a higher metastatic load. The SIM approach resulted in a higher risk of major morbidity and 30-day mortality. Compared to the BFA, the LFA more frequently resulted in failure to complete treatment as planned (34% versus 6%). Pairwise and network meta-analysis showed a similar 5-year OS between LFA and BFA and a more favorable 5-year OS after SIM compared to LFA (odds ratio 0.25-0.90, p = 0.02, I = 0%), but not compared to BFA.

Conclusion: Despite a higher tumor load in LFA compared to BFA patients, survival was similar. A lower rate of treatment completion was observed with LFA. Uncertainty remains substantial due to imprecise estimates of treatment effects. In the absence of prospective trials, treatment of stage IV CRC patients should be individually tailored.
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http://dx.doi.org/10.1016/j.ejso.2020.02.040DOI Listing
July 2020

Reply to: "Nomogram to predict surgical hepatocellular carcinoma with Child-Pugh B: Feasibility and overlooked predictors".

J Hepatol 2020 05 29;72(5):1033-1034. Epub 2020 Feb 29.

Department of Human Structure and Repair, Ghent University, Belgium and Dept. of Clinical Medicine and Surgery, Federico II University, Naples, Italy; Centre for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Tokyo, Japan; Department of HPB Surgery, King Faisal Hospital and Research Center, Al Faisal University, Riyadh, KSA. Electronic address:

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http://dx.doi.org/10.1016/j.jhep.2020.02.002DOI Listing
May 2020

Impact of resection margins for colorectal liver metastases in laparoscopic and open liver resection: a propensity score analysis.

Surg Endosc 2021 Feb 27;35(2):809-818. Epub 2020 Feb 27.

Department of Hepatobiliary and Pancreatic Surgery, University Hospital Southampton NHS Foundation Trust, E Level Tremona Road, Southampton, SO16 6YD, UK.

Background: There is no clear consensus over the optimal width of resection margin for colorectal liver metastases (CRLM), with evolving definitions alongside the advances on the management of the disease. In addition, data on the impact of resection margin after laparoscopic liver resection are still scarce.

Methods: Prospectively maintained databases of patients undergoing open or laparoscopic CRLM resection in 7 European tertiary hepatobiliary referral centres were reviewed. After propensity score matching (PSM), the influence of 1 mm and wider margins on OS and DFS were evaluated in open and laparoscopic cohorts.

Results: After PSM, 648 patients were comparable in each group. The incidence of positive margins (< 1 mm) was similar in open and laparoscopic groups (17% vs 13%, p = 0,142). Margins < 1 mm were associated with shorter RFS in open (12 vs 26 months, p = 0.042) and in laparoscopic group (13 vs 23, p = 0,002). Margins < 1 mm were associated with shorter OS in open (36 vs 57 months, p = 0.027), but not in laparoscopic group (49 vs 60, p = 0,177). Subgroups with margins ≥ 1 mm (1-4 mm, 5-9 mm, ≥ 10 mm) presented similar RFS in open (p = 0,251) or laparoscopic cohorts (p = 0.117), as well as similar OS in open (p = 0.295) or laparoscopic cohorts (p = 0.908). In the presence of liver recurrence, repeat liver resection was performed in 70 (30%) patients in the open group and 88 (48%) in the laparoscopic group (p < 0.001).

Conclusions: Our study suggests that a positive resection margin (less than 1 mm) width does not impact OS after laparoscopic resection of CRLMs as it does in open liver resection. However, a positive margin continues to affect RFS in open and laparoscopic resection. Wider margins than 1 mm do not seem to improve oncological results in open or laparoscopic surgery.
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http://dx.doi.org/10.1007/s00464-020-07452-4DOI Listing
February 2021

Laparoscopic Versus Open Thermal Ablation of Colorectal Liver Metastases: A Propensity Score-Based Analysis of Local Control of the Ablated Tumors.

Ann Surg Oncol 2020 Jul 14;27(7):2370-2380. Epub 2020 Feb 14.

Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy.

Background: Laparoscopic ablation (LA) of colorectal liver metastases (CRLMs) is frequently performed in combination with laparoscopic liver resection or as a stand-alone procedure. However, LA is technically demanding and whether the results are comparable with those of open ablation (OA) has not been determined to date. This study compared the effectiveness of LA and OA in achieving local tumor control of CRLMs.

Methods: Patients undergoing LA or OA of CRLMs at Ghent University Hospital between June 2007 and February 2018 were identified from a prospective database. Lesions treated by LA and OA were matched 1:1 using a propensity score based on lesions (liver segment, size, deepness, proximity to a vessel), patients, and procedural characteristics. Ablation sites were followed up with computed-tomography or magnetic resonance imaging to assess the completeness of the ablation and ablation-site recurrence (ASR). Analysis of ASR was performed with the Kaplan-Meier method and Cox regression.

Results: In this study, 163 patients underwent the surgical ablation (78 LA, 85 OA) of 333 CRLMs (143 LA, 190 OA). After matching, 220 lesions (110 LA, 110 OA) were analyzed. Ablation was complete in 93.7% (LA) and 97.3% (OA) of the sites (p = 0.195). No difference in ASR was observed (p = 0.351), with a cumulative risk of ASR at 12 months of 9.1% (LA) and 8.2% (OA). After multivariable analysis, ASR was confirmed to be independent of the surgical approach.

Conclusion: The findings showed that LA and OA achieve a comparable local control of CRLMs. This result further supports the adoption of a laparoscopic approach for the treatment of CRLMs.
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http://dx.doi.org/10.1245/s10434-020-08243-wDOI Listing
July 2020

Robotic approach to the liver: Open surgery in a closed abdomen or laparoscopic surgery with technical constraints?

Surg Oncol 2020 Jun 25;33:239-248. Epub 2019 Oct 25.

Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy.

The application of the minimally invasive approach has shown to be safe and effective for liver surgery and is in constant growth. The indications for laparoscopic surgery are steadily increasing across the field. In the early 2000s, robotic surgery led to some additional improvements, such as tremor filtration, instrument stability, 3D view and more comfort for the surgeon. These techniques bring in some advantages compared to the traditional OLR: less blood loss, shorter admissions, fewer adhesions, and a faster postoperative recovery and better outcomes in case of further hepatectomy for tumor recurrence has been shown. Concerning which is the best minimally invasive approach between laparoscopic and robotic surgery, the evidence is still conflicting. The latter shows good potential, since the endo-wristed instruments work similarly to the surgeon's hands, even with an intact abdominal wall. However, the technique is still under development, burdened by important costs, and limited by the lack of some instruments available for the laparoscopic approach. The paucity of universally accepted and proven data, especially concerning long-term outcomes, hampers drawing univocal acceptance at present. Furthermore, the number of variables related both to the patient and the disease further complicates the decision leading to a treatment tailored to each patient with strict selection. This review aims to explore the main differences between laparoscopic and robotic surgery, focusing on indications, operative technique and current debated clinical issues in recent literature.
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http://dx.doi.org/10.1016/j.suronc.2019.10.012DOI Listing
June 2020

ASO Author Reflections: Laparoscopic Anatomical Resections: Where We Are and Where Should We Go.

Ann Surg Oncol 2019 12 30;26(Suppl 3):751-752. Epub 2019 Sep 30.

Center for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Saitama, Japan.

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http://dx.doi.org/10.1245/s10434-019-07881-zDOI Listing
December 2019

Development of a nomogram to predict outcome after liver resection for hepatocellular carcinoma in Child-Pugh B cirrhosis.

J Hepatol 2020 01 6;72(1):75-84. Epub 2019 Sep 6.

Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy; Department of Human Structure and Repair, Gent University Hospital, Belgium; Department of HPB Surgery and Liver Transplantation, King Faisal Specialist Hospital and Research Center, Al Faisal University, Riyadh, Kingdom of Saudi Arabia. Electronic address:

Background & Aims: Treatment allocation in patients with hepatocellular carcinoma (HCC) on a background of Child-Pugh B (CP-B) cirrhosis is controversial. Liver resection has been proposed in small series with acceptable outcomes, but data are limited. The aim of this study was to evaluate the outcomes of patients undergoing liver resection for HCC in CP-B cirrhosis, focusing on the surgical risks and survival.

Methods: Patients were retrospectively pooled from 14 international referral centers from 2002 to 2017. Postoperative and oncological outcomes were investigated. Prediction models for surgical risks, disease-free survival and overall survival were constructed.

Results: A total of 253 patients were included, of whom 57.3% of patients had a preoperative platelet count <100,000/mm, 43.5% had preoperative ascites, and 56.9% had portal hypertension. A minor hepatectomy was most commonly performed (84.6%) and 122 (48.2%) were operated on by minimally invasive surgery (MIS). Ninety-day mortality was 4.3% with 6 patients (2.3%) dying from liver failure. One hundred and eight patients (42.7%) experienced complications, of which the most common was ascites (37.5%). Patients undergoing major hepatectomies had higher 90-day mortality (10.3% vs. 3.3%; p = 0.04) and morbidity rates (69.2% vs. 37.9%; p <0.001). Patients undergoing an open hepatectomy had higher morbidity (52.7% vs. 31.9%; p = 0.001) than those undergoing MIS. A prediction model for surgical risk was constructed (https://childb.shinyapps.io/morbidity/). The 5-year overall survival rate was 47%, and 56.9% of patients experienced recurrence. Prediction models for overall survival (https://childb.shinyapps.io/survival/) and disease-free survival (https://childb.shinyapps.io/DFsurvival/) were constructed.

Conclusions: Liver resection should be considered for patients with HCC and CP-B cirrhosis after careful selection according to patient characteristics, tumor pattern and liver function, while aiming to minimize surgical stress. An estimation of the surgical risk and survival advantage may be helpful in treatment allocation, eventually improving postoperative morbidity and achieving safe oncological outcomes.

Lay Summary: Liver resection for hepatocellular carcinoma in advanced cirrhosis (Child-Pugh B score) is associated with a high rate of postoperative complications. However, due to the limited therapeutic alternatives in this setting, recent studies have shown promising results after accurate patient selection. In our international multicenter study, we provide 3 clinical models to predict postoperative surgical risks and long-term survival following liver resection, with the aim of improving treatment allocation and eventually clinical outcomes.
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http://dx.doi.org/10.1016/j.jhep.2019.08.032DOI Listing
January 2020

Parenchymal Sparing Anatomical Liver Resections With Full Laparoscopic Approach: Description of Technique and Short-term Results.

Ann Surg 2019 Aug 23. Epub 2019 Aug 23.

Center for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Saitama, Japan.

Objective: The aim of this study was to describe laparoscopic anatomical parenchymal sparing liver resections for hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM) and report the short-term outcomes.

Background: Anatomical resections (ARs) have better oncological outcomes compared to partial resections in patients with HCC, and some suggest should be performed also for CRLM as micrometastasis occurs through the intrahepatic structures. Furthermore, remnant liver ischemia after partial resections has been associated with worse oncological outcomes. Few experiences on laparoscopic anatomical resections have been reported and no data on limited AR exist.

Methods: We performed a retrospective analysis of 86 patients undergoing full laparoscopic anatomical parenchymal sparing resections with preoperative surgical simulation and standardized procedures.

Results: A total of 55 patients had HCC, whereas 31 had CRLM with a median of 1 lesion and a size of 30 mm. During preoperative three-dimensional (3D) simulation, a median resection volume of 120 mL was planned. Sixteen anatomical subsegmentectomies, 56 segmentectomies, and 14 sectionectomies were performed. Concordance between preoperative 3D simulation and intraoperative resection was 98.7%. Two patients were converted, and 7 patients experienced complications. Subsegmentectomies had comparable blood loss (166 mL, P = 0.59), but longer operative time (426 min, P = 0.01) than segmentectomies (blood loss 222 mL; operative time 355 min) and sectionectomies (blood loss 120 mL; operative time 295 min). R0 resection and margin width remained comparable among groups.

Conclusions: A precise preoperative planning and a standardized surgical technique allow to pursue the oncological quality of AR enhancing the safety of the parenchyma sparing principle, reducing surgical stress through a laparoscopic approach.
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http://dx.doi.org/10.1097/SLA.0000000000003575DOI Listing
August 2019

Pure laparoscopic versus open hemihepatectomy: a critical assessment and realistic expectations - a propensity score-based analysis of right and left hemihepatectomies from nine European tertiary referral centers.

J Hepatobiliary Pancreat Sci 2020 Jan 11;27(1):3-15. Epub 2019 Sep 11.

University Hospital Southampton, Southampton, UK.

Introduction: A stronger evidence level is needed to confirm the benefits and limits of laparoscopic hemihepatectomies.

Methods: Laparoscopic and open hemihepatectomies from nine European referral centers were compared after propensity score matching (right and left hemihepatectomies separately, and benign and malignant diseases sub-analyses).

Results: Five hundred and forty-five laparoscopic hemihepatectomies were compared with 545 open. Laparoscopy was associated with reduced blood loss (P < 0.001), postoperative stay (P < 0.001) and minor morbidity (P = 0.002), supported by a lower Comprehensive Complication Index (CCI) (P = 0.035). Laparoscopic right hemihepatectomies were associated with lower ascites (P = 0.016), bile leak (P = 0.001) and wound infections (P = 0.009). Laparoscopic left hemihepatectomies exhibited a lower incidence of bile leak and cardiovascular complications (P = 0.024; P = 0.041), lower minor and major morbidity (P = 0.003; P = 0.044) and reduced CCI (P = 0.002). Laparoscopic major hepatectomies (LMH) for benign disease were associated with lower blood loss (P = 0.001) and bile leaks (P = 0.037) and shorter total stay (P < 0.001). LMH for malignancy were associated with lower blood loss (P < 0.001) and minor morbidity (P = 0.027) supported by a lower CCI (P = 0.021) and shorter stay (P < 0.001).

Conclusion: This multicenter study confirms some associated advantages of laparoscopic left and right hemihepatectomies in malignant and benign conditions highlighting the need for realistic expectations of the minimally invasive approach based on the resected hemiliver and the patients treated.
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http://dx.doi.org/10.1002/jhbp.662DOI Listing
January 2020

Effect of treatment sequence on survival in stage IV rectal cancer with synchronous and potentially resectable liver metastases.

J Surg Oncol 2019 Sep 19;120(3):415-422. Epub 2019 Jun 19.

Department of GI Surgery, Ghent University Hospital, Belgium.

Background And Objectives: The optimal treatment sequence in stage IV rectal cancer (RC) with synchronous liver metastases (SLM) remains undefined. Here, we compared outcomes between patients treated with the bowel-first approach (BFA) or the liver-first approach (LFA).

Methods: Consecutive patients diagnosed with stage IV RC with SLM and who underwent complete resection were included. Both groups were matched using propensity scores. Differences in postoperative outcome, local control, and long-term survival were studied. In addition, a decision analysis (DA) model was built using TreeAge Pro to define the approach that results in the highest treatment completion rate.

Results: During a 12-year period, 52 patients were identified, 21 and 31 of whom underwent the BFA and the LFA, respectively. Twenty-eight patients were matched; patients treated with the BFA experienced a longer median OS (50.0 vs 33.0 months; P = .40) and higher 5-year OS (42.9% vs 28.6%). The DA defined the BFA to be superior when the failure threshold (ie, no R0 resection, treatment discontinuation regardless of cause) for colectomy is less than 28.6%.

Conclusions: In stage IV rectal cancer with SLM, either the BFA or the LFA result in similar long-term outcomes. Treatment should be tailored according to clinicopathological variables.
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http://dx.doi.org/10.1002/jso.25516DOI Listing
September 2019

Pathologist second opinion significantly alters clinical management of pT1 endoscopically resected colorectal cancer.

Virchows Arch 2019 Nov 17;475(5):665-668. Epub 2019 Jun 17.

Faculty of Medicine and Psychology, Department of Clinical and Molecular Medicine, University of Rome "Sapienza", Santo Andrea Hospital, via di Grottarossa 1035, 00189, Rome, Italy.

We retrospectively collected a series of 82 endoscopically removed early colorectal cancers. Histological specimens were revised by two gastrointestinal pathologists, performing a re-evaluation of all risk factors for lymph node metastasis. The comparison between second opinion and first pathological report revealed that lymphovascular invasion and tumor grading showed a lower level of concordance than other parameters. Our results demonstrated that second opinion modified risk assessment in about 10% of cases. It was mainly due to a lack in reporting of some parameters at the first diagnosis and a different evaluation in second opinion for updated guidelines. Considering the subgroup of patients with modified risk assessment, clinical data revealed that tumors, re-classified as low risk, did not develop lymph node metastasis that, conversely, occurred in patients identified as high risk by second opinion. In conclusion, second opinion significantly alters risk perception of endoscopically removed early colorectal carcinomas representing a valuable tool for their appropriate clinical management.
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http://dx.doi.org/10.1007/s00428-019-02603-yDOI Listing
November 2019

Full Laparoscopic Anatomical Segment 8 Resection for Hepatocellular Carcinoma Using the Glissonian Approach with Indocyanine Green Dye Fluorescence.

Ann Surg Oncol 2019 Aug 7;26(8):2577-2578. Epub 2019 May 7.

Center for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Saitama, Japan.

Background: Anatomical resections have been reported to achieve better long-term outcomes compared with partial resections for the treatment of hepatocellular carcinoma (HCC). Despite this, laparoscopic anatomical resections are very challenging operations, especially when approaching the posterosuperior segments of the liver (IVa, VII, and VIII). We report a full laparoscopic anatomical segment 8 resection focusing on the technical aspects of the Glissonian approach.

Methods: A routine follow-up CT scan of an 80-year-old women affected by hepatitis C-related liver cirrhosis showed a 3-cm HCC in segment 8. Three-dimensional reconstruction was performed to evaluate the liver anatomy, the relationship of the lesion with major vessels, and the borders of segment 8. A true anatomical segmentectomy was performed by using selective occlusion of segment's 8 Glissonian pedicle, which was identified from the liver hilum. Indocyanine green (ICG) dye demarcation was used as a guidance during parenchymal transection.14 RESULTS: Operative time was 420 min, and blood loss was 261 mL. The patient had an uneventful postoperative course and was discharged home after 8 days.

Conclusions: Full laparoscopic anatomical segment 8 resection is a technically challenging operation. The use of the Glissonian approach and the aid of ICG dye could be of help, but advanced laparoscopic skills are necessary to complete such a difficult procedure safely.513.
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http://dx.doi.org/10.1245/s10434-019-07422-8DOI Listing
August 2019

Laparoscopic liver resection-education and training.

Transl Gastroenterol Hepatol 2019 18;4:11. Epub 2019 Feb 18.

Center for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Tokyo, Japan.

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http://dx.doi.org/10.21037/tgh.2019.01.10DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6414331PMC
February 2019

Recurrence Following Anastomotic Leakage After Surgery for Carcinoma of the Distal Esophagus and Gastroesophageal Junction: A Systematic Review.

Anticancer Res 2019 Apr;39(4):1651-1660

General Surgery Unit, Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Rome, Italy.

Background: Esophageal cancer is the ninth most common cancer. The only potentially curative treatment is surgical resection, which unfortunately is still associated with major complications, the most important being anastomotic leakage, currently with an overall rate of up to 26% morbidity. The aim of this systematic review was to evaluate the relationship between anastomotic leakage and recurrence of disease.

Materials And Methods: A literature search was systematically performed. Seven out of 312 articles dated between 2009 and 2018 fulfilled the selection for a total of 5,433 patients.

Results: The frequency of anastomotic leakage ranged from 7.2 to 11.2%. Patients affected by anastomotic leakage had a recurrence rate of 9-56%.

Conclusion: Closer follow-up or even more aggressive oncological therapy should be considered for patients affected by anastomotic leakage after surgery for carcinoma of the distal esophagus and gastroesophageal junction.
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http://dx.doi.org/10.21873/anticanres.13270DOI Listing
April 2019

Clinical management of endoscopically resected pT1 colorectal cancer.

Endosc Int Open 2018 Dec 12;6(12):E1462-E1469. Epub 2018 Dec 12.

Endoscopy Unit, Azienda Ospedaliera Sant'Andrea, "Sapienza" University of Rome, Rome, Italy.

 Implementation of colorectal cancer (CRC) screening programs increases endoscopic resection of polyps with early invasive CRC (pT1). Risk of lymph node metastasis often leads to additional surgery, but despite guidelines, correct management remains unclear. Our aim was to assess the factors affecting the decision-making process in endoscopically resected pT1-CRCs in an academic center.  We retrospectively reviewed patients undergoing endoscopic resection of pT1 CRC from 2006 to 2016. Clinical, endoscopic, surgical treatment, and follow-up data were collected and analyzed. Lesions were categorized according to endoscopic/histological risk-factors into low and high risk groups. Comorbidities were classified according to the Charlson comorbidity index (CCI). Surgical referral for each group was computed, and dissociation from current European CRC screening guidelines recorded. Multivariate analysis for factors affecting the post-endoscopic surgery referral was performed.  Seventy-two patients with endoscopically resected pT1-CRC were included. Overall, 20 (27.7 %) and 52 (72.3 %) were classified as low and high risk, respectively. In the low risk group, 11 (55 %) were referred to surgery, representing over-treatment compared with current guidelines. In the high risk group, nonsurgical endoscopic surveillance was performed in 20 (38.5 %) cases, representing potential under-treatment. After a median follow-up of 30 (6 - 130) months, no patients developed tumor recurrence. At multivariate analysis, age (OR 1.21, 95 %CI 1.02 - 1.42;  = 0.02) and CCI (OR 1.67, 95 %CI 1.12 - 3.14;  = 0.04) were independent predictors for subsequent surgery.  A substantial rate of inappropriate post-endoscopic treatment of pT1-CRC was observed when compared with current guidelines. This was apparently related to an overestimation of patient-related factors rather than endoscopically or histologically related factors.
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http://dx.doi.org/10.1055/a-0781-2293DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6291400PMC
December 2018

The ALPPS procedure: hepatocellular carcinoma as a main indication. An Italian single-center experience.

Updates Surg 2019 Mar 25;71(1):67-75. Epub 2018 Sep 25.

Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Circ.ne Gianicolense 87, 00151, Rome, Italy.

The ALPPS is a technique that allows achieving hepatic resection by a rapid future liver remnant hypertrophy. The aim of this study was to report the experience of an Italian center with ALPPS in patients with liver tumors. A retrospective analysis of patients undergoing ALPPS between 2012 and 2017 was performed. Patients' characteristics and disease presentation, increase in future liver remnant (FLR) as well as intraoperative and postoperative short- and long-term outcomes were evaluated. A total of 24 patients underwent the ALPPS procedure: 17 procedures for hepatocarcinoma (HCC), 5 for colorectal liver metastases (CRLM), 1 for cholangiocarcinoma (CC) and 1 for Merkel Cell Carcinoma liver metastasis (MCCLM). Macrovascular invasion (MVI) was recorded in 10 (41.6%) patients: 8 (33.3%) patients with HCC had invasion of portal vein (5), middle hepatic vein (2) and inferior vena cava (1). One patient with CRLM had involvement of middle hepatic vein and one patient with CC had involvement of right portal vein and middle hepatic vein. A p-ALPPS in 14 cases (58.3%), 10 t-ALPPS (41.6%) and hanging maneuver in 19 patients (80%) were performed. Median postoperative stay was 26 days (range 16-68 days). 90-day mortality was 8.3% (two patients, one with CC and one with HCC), 90-day mortality for HCC was 5.8%. After stage 1, we counted 15 complications all of grade I; after stage 2 the number of complications was increased to 37:33 were of grade I and 4 were of grade IV. R0 resection was achieved in all patients with 100% oncology feasibility. After a median follow-up of 10 months (range 2-54), disease recurrence has been recorded in 6 patients with HCC and in 2 with CRLM. Eleven patients died, nine affected by HCC, one by CRLM, and one by CC. 2-years OS and disease-free survival (DFS) for the entire group were 47.3% and 47.5%, respectively. Concerning patients operated on for HCC, the 2-years OS and DFS were 38.5% and 60%, respectively. The ALPPS procedure is an interesting approach for large primary or secondary liver tumor with small FLR above all for large HCC associated with MVI, with acceptable OS and DFS.
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http://dx.doi.org/10.1007/s13304-018-0596-3DOI Listing
March 2019

Is a Surgical Approach Justified in Metachronous Krukenberg Tumor from Gastric Cancer? A Systematic Review.

Oncol Res Treat 2018 12;41(10):644-649. Epub 2018 Sep 12.

Background: The treatment of metachronous Krukenberg tumor (mKT) from gastric cancer remains unexplored. We performed a literature review to evaluate whether or not surgical treatment improves survival.

Methods: A systematic review according to PRISMA guidelines was performed. Studies reporting on patients who underwent surgical treatment for mKT from gastric cancer were selected. Metachronous disease was divided as follows: confined to the ovaries, confined to the pelvis, or beyond the pelvis. Outcomes evaluated included overall survival (OS), progression-free survival (PFS), resection rate (R0), and factors predicting survival.

Results: 13 retrospective reports fulfilled the selection criteria (512 patients). Most of the patients presented at a premenopausal age. The median presentation interval from gastrectomy ranged from 16 to 21.4 months. Median OS ranged between 9 and 36 months. 1-year OS ranged between 52.5 and 59%, and 3-years OS between 9.8 and 36.5%. Resection margin, peritoneal seeding, and chemotherapy regimen and cycles influenced survival.

Conclusion: Surgical treatment and adjuvant chemotherapy in patients with mKT from gastric cancer seems to be associated with improved survival and is justified especially in young patients. Disease location and R0 resection should be considered when selecting patients.
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http://dx.doi.org/10.1159/000490956DOI Listing
August 2019

A Comparison of the Learning Curves of Laparoscopic Liver Surgeons in Differing Stages of the IDEAL Paradigm of Surgical Innovation: Standing on the Shoulders of Pioneers.

Ann Surg 2019 02;269(2):221-228

Department of Hepatopancreatobiliary Surgery, University Hospital Southampton, Southampton, UK.

Objective: To compare the learning curves of the self-taught "pioneers" of laparoscopic liver surgery (LLS) with those of the trained "early adopters" in terms of short- and medium-term patient outcomes to establish if the learning curve can be reduced with specific training.

Summary Of Background Data: It is expected that a wider adoption of a laparoscopic approach to liver surgery will be seen in the next few years. Current guidelines stress the need for an incremental, stepwise progression through the learning curve in order to minimize harm to patients. Previous studies have examined the learning curve in Stage 2 of the IDEAL paradigm of surgical innovation; however, LLS is now in stage 3 with specific training being provided to surgeons.

Methods: Using risk-adjusted cumulative sum analysis, the learning curves and short- and medium-term outcomes of 4 "pioneering" surgeons from stage 2 were compared with 4 "early adapting" surgeons from stage 3 who had received specific training for LLS.

Results: After 46 procedures, the short- and medium-term outcomes of the "early adopters" were comparable to those achieved by the "pioneers" following 150 procedures in similar cases.

Conclusions: With specific training, "early adapting" laparoscopic liver surgeons are able to overcome the learning curve for minor and major liver resections faster than the "pioneers" who were self-taught in LLS. The findings of this study are applicable to all surgical specialties and highlight the importance of specific training in the safe expansion of novel surgical practice.
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http://dx.doi.org/10.1097/SLA.0000000000002996DOI Listing
February 2019

Learning Curve Under Proctorship of Pure Laparoscopic Living Donor Left Lateral Sectionectomy for Pediatric Transplantation.

Ann Surg 2020 03;271(3):542-548

Organ Transplant Center, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.

Objective: To evaluate the learning curve of an expert liver transplantation surgeon approaching fully laparoscopic living donor left lateral sectionectomy (L-LLS) under proctorship.

Background: Laparoscopic liver resections necessitate a long learning curve trough a stepwise fulfillment of difficulties. L-LLS requires expertise in both living donor liver transplantation and advanced laparoscopic liver surgery. There is currently no data about the learning curve of L-LLS.

Methods: A total of 72 pure L-LLS were included in this study. A Broken line model was used to identify the periods of the learning curve. A CUSUM analysis of the operative time was performed to evaluate improvements of outcomes with time. To evaluate the relationship between operative time and progressive number of procedures, a linear regression model was applied. A receiver operating characteristic (ROC) curve was carried out to identify the cutoff for completion of the learning curve.

Results: Operative time decreased with the progressive increase of procedures. Two cutoffs and 3 different periods were identified: cases 1 to 22, cases 23 to 55, and cases 56 to 72. A significant decrease in blood loss and operative time was noted. The CUSUM analysis showed an increase in operative time in the first period, a stable duration in the second period, and a decrease in the last. Blood loss was significantly associated with an increase in operative time (P = 0.003). According to the ROC curve, the learning curve was completed after 25 procedures.

Conclusions: L-LLS is a safe procedure that can be standardized and successfully taught to surgeons with large experience in donor hepatectomy through a proctored learning curve.
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http://dx.doi.org/10.1097/SLA.0000000000002948DOI Listing
March 2020