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Fermi F, Ratti F, Stepanyan P, Corallino D, Ingallinella S, Reineke R, Beretta L, Aldrighetti L. Navigator nurse implementation within a fast track program of liver resections: How to improve the healthcare service and perioperative results. World J Surg 2024; 48:193-202. [PMID: 38526497 DOI: 10.1002/wjs.12026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 11/06/2023] [Indexed: 03/26/2024]
Abstract
BACKGROUND The introduction into the clinical practice of the navigator nurse (NaNu) to address the task of counseling and short term follow-up help the effective implementation of the fast track protocol. The aim of the present study was to investigate the impact of the standardization of the NaNu's role in patients undergoing liver surgery. METHODS Patients undergoing elective liver surgery for all diagnosis and approach, from 2015, received counseling and postoperative follow-up by NaNu and constituted the study group (n = 890). This group was compared with the control group (n = 712) including patients treated in the era before the implementation of the NaNu role (2011-2014). Outcome was evaluated in terms of discrepancy between functional recovery and discharge, number of ER accesses, number of readmissions. RESULTS Preoperative characteristics of patients and disease, as well as type of resection and postoperative outcomes were similar between the two groups. The proportion of laparoscopic cases was higher in the study group (51.2% vs. 32% in the control). Time for discharge, interval between functional recovery and discharge, number of ER accesses and number of readmissions were reduced in the study group. Benign diagnosis, absence of complications, laparoscopic approach and presence of NaNu were independent predictors of shorter length of stay. The positive effect of NaNu's activation was recorded in patients with complications and undergoing open surgery. CONCLUSION The implementation of NaNu's role has allowed to us optimize the level of healthcare service offered to patients. The wider benefit was offered in the setting of complex patients.
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Affiliation(s)
- Francesca Fermi
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy
| | - Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy
- Vita-Salute San Raffaele University, Milano, Italy
| | | | - Diletta Corallino
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy
| | - Sara Ingallinella
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy
| | - Raffaella Reineke
- Anaesthesiology and Intensive Care Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Luigi Beretta
- Anaesthesiology and Intensive Care Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy
- Vita-Salute San Raffaele University, Milano, Italy
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2
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Pascale MM, Ratti F, Cipriani F, Marino R, Catena M, Clocchiatti L, Buonanno S, Aldrighetti L. A "cui prodest" evaluation on the development of a minimally invasive liver surgery program: a differential benefit analysis of open and laparoscopic approach for left and right hemihepatectomies. Surg Endosc 2023; 37:8204-8213. [PMID: 37648797 DOI: 10.1007/s00464-023-10382-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 08/06/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND The correlation between technical feasibility and short-term clinical advantage provided by laparoscopic over open technique for major hepatectomies is unclear. This monocentric retrospective study investigates the possible differences in the benefit provided by minimally invasive approach between left and right hepatectomy, deepening the concept of differential benefit in the setting of anatomical major resections. METHODS All hemihepatectomies performed from January 2004 to December 2021 were identified in the institutional database. A propensity score method was used to match minimal invasive (MILS) and open pairs in the left hemihepatectomies (LH) and right hemihepatectomies (RH) groups with a 1:1 ratio to adjust any potential selection bias. The differential benefit for left and right hepatectomy provided by laparoscopic over open technique was evaluated in a pure analysis (i.e., including cases converted to open) and a risk-adjusted analysis (i.e., after excluding open conversion from the laparoscopic series). RESULTS The analysis of the risk-adjusted differential benefit demonstrated better result of the MILS in the RH group than in the LH group, in terms of blood loss (∆ blood loss - 150 and - 350, respectively; differential benefit: 200 mL, p < 0.05), morbidity (∆ rate of morbidity - 11.3% and - 18.1%, respectively; differential benefit: 6.8%, p < 0.05) and length of stay, LOS (∆ LOS - 1 day and - 3 days, respectively; differential benefit: 2 days, p < 0.05). CONCLUSION While MILS is associated with improved clinical outcomes both in left and right hepatectomy procedures, the greater advantage provided by laparoscopy was documented in patients undergoing right hepatectomy, i.e. for more technically demanding procedures. A MILS program should include the broadest range of liver resections to ensure the full benefits of the laparoscopic technique.
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Affiliation(s)
- Marco Maria Pascale
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy
| | - Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy.
- Faculty of Medicine, University Vita-Salute San Raffaele, 20132, Milan, Italy.
| | - Federica Cipriani
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy
| | - Rebecca Marino
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy
| | - Marco Catena
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy
| | - Lucrezia Clocchiatti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy
| | - Silvia Buonanno
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, 20132, Milan, Italy
- Faculty of Medicine, University Vita-Salute San Raffaele, 20132, Milan, Italy
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3
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Cipriani F, Ratti F, Fornoni G, Marino R, Tudisco A, Catena M, Aldrighetti L. Conversion of Minimally Invasive Liver Resection for HCC in Advanced Cirrhosis: Clinical Impact and Role of Difficulty Scoring Systems. Cancers (Basel) 2023; 15:cancers15051432. [PMID: 36900223 PMCID: PMC10001094 DOI: 10.3390/cancers15051432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/13/2023] [Accepted: 02/22/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Minimally invasive liver resections (MILRs) in cirrhosis are at risk of conversion since cirrhosis and complexity, which can be estimated by scoring systems, are both independent factors for. We aimed to investigate the consequence of conversion of MILR for hepatocellular carcinoma in advanced cirrhosis. METHODS After retrospective review, MILRs for HCC were divided into preserved liver function (Cohort-A) and advanced cirrhosis cohorts (Cohort-B). Completed and converted MILRs were compared (Compl-A vs. Conv-A and Compl-B vs. Conv-B); then, converted patients were compared (Conv-A vs. Conv-B) as whole cohorts and after stratification for MILR difficulty using Iwate criteria. RESULTS 637 MILRs were studied (474 Cohort-A, 163 Cohort-B). Conv-A MILRs had worse outcomes than Compl-A: more blood loss; higher incidence of transfusions, morbidity, grade 2 complications, ascites, liver failure and longer hospitalization. Conv-B MILRs exhibited the same worse perioperative outcomes than Compl-B and also higher incidence of grade 1 complications. Conv-A and Conv-B outcomes of low difficulty MILRs resulted in similar perioperative outcomes, whereas the comparison of more difficult converted MILRs (intermediate/advanced/expert) resulted in several worse perioperative outcomes for patients with advanced cirrhosis. However, Conv-A and Conv-B outcomes were not significantly different in the whole cohort where "advanced/expert" MILRs were 33.1% and 5.5% in Cohort A and B. CONCLUSIONS Conversion in the setting of advanced cirrhosis can be associated with non-inferior outcomes compared to compensated cirrhosis, provided careful patient selection is applied (patients elected to low difficulty MILRs). Difficulty scoring systems may help in identifying the most appropriate candidates.
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Affiliation(s)
- Federica Cipriani
- Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Correspondence:
| | - Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Gianluca Fornoni
- Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Rebecca Marino
- Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Antonella Tudisco
- Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Marco Catena
- Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, 20132 Milan, Italy
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4
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Individual components of post-hepatectomy care pathways have differential impacts on length of stay. Am J Surg 2023; 225:53-57. [PMID: 36207173 DOI: 10.1016/j.amjsurg.2022.09.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND The value of individual variable contributions to post-hepatectomy length of stay (LOS) are difficult to quantify within bundled care pathways. METHODS Poisson regression and marginal effects models for prolonged post-hepatectomy LOS (>25% median) included Kawaguchi-Gayet (KG) complexity, perioperative variables, and pathways (minimally-invasive = MIS; low-intermediate-risk = KGI/II; high-risk = KGIII; combination). RESULTS Median LOS was 2, 4, 5, and 5 days for MIS, KGI/II, KGIII and combination pathways (N = 978). Poisson regression identified age, intraoperative fluids, delayed diet tolerance, and combination cases as associated with increased LOS (p < 0.01). Marginal effects analysis demonstrated the following added probability of longer LOS: each year of age 0.03x, 250 mL intraoperative fluids 0.06x, each operative hour 0.2x, additional day before diet tolerance 0.4x, combination cases 0.7x. MIS was associated with 1.2x increased probability of shorter LOS. CONCLUSIONS Optimizing intraoperative fluids, operative time, and postoperative diet, while favoring MIS approach when feasible, may maximize effects of post-hepatectomy care pathways to reduce LOS.
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Zhou J, He X, Wang M, Zhao Y, Zhang N, Wang L, Mao A, Wang L. Enhanced Recovery After Surgery in Patients With Hepatocellular Carcinoma Undergoing Laparoscopic Hepatectomy. Front Surg 2021; 8:764887. [PMID: 34881286 PMCID: PMC8645578 DOI: 10.3389/fsurg.2021.764887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/21/2021] [Indexed: 01/08/2023] Open
Abstract
Objective: To compare the effectiveness and safety of enhanced recovery after surgery (ERAS) in patients with hepatocellular carcinoma (HCC) undergoing laparoscopic hepatectomy. Methods: From September 2016 to June 2019, 282 patients were enrolled, and ERAS was implemented since March 2018. All indicators related to surgery, liver function, and postoperative outcomes were included in the analysis. Propensity score matching (PSM) identified 174 patients for further comparison. Results: After PSM, the clinicopathological baselines were well-matched. The group showed significantly less intraoperative blood loss (100.00 [100.00–200.00] vs. 200.00 [100.00–300.00] ml, P = 0.001), fewer days before abdominal drainage tube removal (4.00 [3.00–4.00] days vs. 4.00 [3.00–5.00] days, P = 0.023), shorter hospital stay after surgery (6.00 [5.00–6.00] days vs. 6.00 [6.00–7.00] days, P < 0.001), and reduced postoperative morbidity (18.39 vs. 34.48%, P = 0.026). The proportion of patients with a pain score ≥ 4 was significantly lower in the ERAS group within the first 2 days after surgery (1.15 vs. 13.79% and 8.05 vs. 26.44%, P = 0.002 and P = 0.001, respectively). Pringle maneuver was performed more frequently in the ERAS group (70.11 vs. 18.39%, P < 0.001), and a significantly higher postoperative alanine aminotransferase level was also observed (183.40 [122.85–253.70] vs. 136.20 [82.93–263.40] U/l, P = 0.026). The 2-year recurrence-free survival was similar between the two groups (72 vs. 71%, P = 0.946). Conclusions: ERAS programs are feasible and safe and do not influence mid-term recurrence in HCC patients undergoing laparoscopic hepatectomy.
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Affiliation(s)
- Jiamin Zhou
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xigan He
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Miao Wang
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yiming Zhao
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ning Zhang
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Longrong Wang
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Anrong Mao
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Lu Wang
- Department of Hepatic Surgery, Shanghai Cancer Center, Fudan University, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Ratti F, Nini A, Bertini R, Aldrighetti L. Vascular occlusion to protect against intraoperative blood loss in liver surgeries: new perspectives on a traditional technique. Hepatobiliary Surg Nutr 2021; 10:567-569. [PMID: 34430546 DOI: 10.21037/hbsn-21-128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 04/15/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alessandro Nini
- Department of Urology, IRCCS, San Raffaele Scientific Institute, Milan, Italy.,Division of Experimental Oncology/Unit of Urology, URI, IRCCS San Raffaele Hospital, Milan, Italy.,Department of Urology and Pediatric Urology, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Roberto Bertini
- Department of Urology, IRCCS, San Raffaele Scientific Institute, Milan, Italy.,Division of Experimental Oncology/Unit of Urology, URI, IRCCS San Raffaele Hospital, Milan, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
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7
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Ratti F, Serenari M, Zanello M, Fuks D, Rottoli M, Masetti M, Tribillon E, Ravaioli M, Elmore U, Rosati R, Gayet B, Cescon M, Jovine E, Aldrighetti L. Team Strategy Optimization in Combined Resections for Synchronous Colorectal Liver Metastases. A Comparative Study with Bootstrapping Analysis. World J Surg 2021; 45:3424-3435. [PMID: 34313830 DOI: 10.1007/s00268-021-06260-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim of the study was to evaluate perioperative outcomes and to evaluate factors influencing rative morbidity and adoption of minimally invasive technique in 1-team (1-T) versus two teams (2-T) management of synchronous colorectal liver metastases. METHODS Within four referral centers, a group of 234 patients treated in 1-T centers was identified and compared with a group of 253 patients treated in 2-T. A nonparametric bootstrap process was applied to the original cohorts of 1-T group and 2-T group as a resampling method to obtain bootstrapped cohorts (155 patients per group). RESULTS 33.5% of patients in 1-T boot group and 38.1% in the 2-T boot group were operated by laparoscopic approach. Multivariate analysis revealed that approach to primary tumor (laparoscopic or open) and intraoperative blood loss were independent prognostic factors for morbidity. Team approach did not show any significant correlation with incidence of postoperative complications nor with choice for laparoscopic approach. CONCLUSION The optimization of team strategy for patients with SCRLM is not solely based on the adoption of a 1-T or 2-T approach, but should instead be based on the implementation of a standard protocol for management of these patients.
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Affiliation(s)
- Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milano, Italy.
| | - Matteo Serenari
- General Surgery and Transplant Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Matteo Zanello
- Department of General Surgery, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Maggiore Hospital, Bologna, Italy
| | - David Fuks
- Department of Digestive Disease, Institut Mutualiste Montsouris, Paris, France
| | - Matteo Rottoli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,Surgery of the Alimentary Tract, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Michele Masetti
- Department of General Surgery, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Maggiore Hospital, Bologna, Italy
| | - Ecoline Tribillon
- Department of Digestive Disease, Institut Mutualiste Montsouris, Paris, France
| | - Matteo Ravaioli
- General Surgery and Transplant Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Ugo Elmore
- Division of Gastrointestinal Surgery, Azienda Ospedaliero-Universitaria di Bologna, San Raffaele Hospital, Milano, Italy
| | - Riccardo Rosati
- Division of Gastrointestinal Surgery, Azienda Ospedaliero-Universitaria di Bologna, San Raffaele Hospital, Milano, Italy
| | - Brice Gayet
- Department of Digestive Disease, Institut Mutualiste Montsouris, Paris, France
| | - Matteo Cescon
- General Surgery and Transplant Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Elio Jovine
- Department of General Surgery, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Maggiore Hospital, Bologna, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milano, Italy
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8
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Ratti F, Rawashdeh A, Cipriani F, Primrose J, Fiorentini G, Abu Hilal M, Aldrighetti L. Intrahepatic cholangiocarcinoma as the new field of implementation of laparoscopic liver resection programs. A comparative propensity score-based analysis of open and laparoscopic liver resections. Surg Endosc 2021; 35:1851-1862. [PMID: 32342213 DOI: 10.1007/s00464-020-07588-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 04/22/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND The aim of the present study is to analyze the outcomes of laparoscopic and open liver resections for (Intrahepatic CholangioCarcinoma) ICC in the modern era of laparoscopic liver surgery. METHODS Patients undergoing laparoscopic and open liver resections for ICC in two European referral centers were included. Finally, 104 patients from the open group and 104 patients from the laparoscopic group were compared after propensity scores matching according to seven covariates representative of patients and disease characteristics. Indications to surgery and short- and long-term outcomes were compared. RESULTS Operative time, number of retrieved nodes, rate, and depth of negative resection margins were comparable between the two groups. Blood loss was lower in the MILS (150 ± 100 mL, mean ± SD) compared with the Open group (350 ± 250 mL, p = 0.030). Postoperative complications occurred in 14.4% of patients in the MILS and in the 24% of patients in the Open group (p = 0.02). There were no significant differences in long-term outcomes between groups. CONCLUSIONS Our results confirm feasibility, safety, and oncological efficiency of the laparoscopic approach in the management of ICC. However, this surgery is often complex and should be only considered in centers with large experience in laparoscopic liver surgery.
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Affiliation(s)
- Francesca Ratti
- Hepatobiliary Surgery Division, San Raffaele Hospital, Via Olgettina 60, 20132, Milano, Italy.
| | - Arab Rawashdeh
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Southampton, NHS Foundation Trust, Southampton, UK
| | - Federica Cipriani
- Hepatobiliary Surgery Division, San Raffaele Hospital, Via Olgettina 60, 20132, Milano, Italy
| | - John Primrose
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Southampton, NHS Foundation Trust, Southampton, UK
| | - Guido Fiorentini
- Hepatobiliary Surgery Division, San Raffaele Hospital, Via Olgettina 60, 20132, Milano, Italy
| | - Mohammed Abu Hilal
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Southampton, NHS Foundation Trust, Southampton, UK
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, San Raffaele Hospital, Via Olgettina 60, 20132, Milano, Italy
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9
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Fiorentini G, Ratti F, Cipriani F, Marino R, Cerchione R, Catena M, Paganelli M, Aldrighetti L. Correlation Between Type of Retrieval Incision and Postoperative Outcomes in Laparoscopic Liver Surgery: A Critical Assessment. J Laparoendosc Adv Surg Tech A 2020; 31:423-432. [PMID: 32833591 DOI: 10.1089/lap.2020.0470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background: At the end of a laparoscopic major hepatectomy, an incision wide enough for specimen retrieval is required. Classically, Pfannenstiel (PF) incision is the type of access favored as service incision in laparoscopy. However, in specific settings the use of a midline (ML) incision can be favorable, with doubtful impaction on the outcomes of a purely laparoscopic operation. The aim of this study was to investigate on clinical outcomes after laparoscopic hemihepatectomies using PF/ML incisions in comparison with open. Methods: The institutional clinical database of the Hepatobiliary Division at San Raffaele Hospital (Milan, Italy) was retrospectively reviewed identifying cases of laparoscopic and open hemihepatectomies. Three analyses were performed: whole laparoscopic versus open; ML versus open; PF versus ML. Clinical outcomes such as intraoperative blood loss, operative time, postoperative morbidity, motility resumption, perceived pain, and length of stay (LOS) were used for comparisons. Results: Laparoscopy was confirmed to be superior to open approach also in the present series in terms of lower blood loss (300 versus 400 mL, P = .041), fewer complications (14.2% versus 25.9%, P = .024), shorter hospitalization (5 versus 7 days, P = .033), and enhanced recovery in terms of better pain control (P = .035) and mobility resumption (P = .047). Similar outcomes were observed comparing ML alone with open (estimated blood loss 300 mL versus 400 mL, P = .039; complications 13.1% versus 25.9%, P = .037; LOS 5 days versus 7 days, P = .04; lower pain perception, P = .048 and faster mobility resumption, P = .046). No significant differences were observed in postoperative outcomes of PF versus ML. Conclusions: Suprapubic and ML incisions at the end of a pure laparoscopic case lead to comparable outcomes between each other. The adoption of ML incision for specimen retrieval does not affect outcomes of minimal invasiveness.
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Affiliation(s)
- Guido Fiorentini
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy.,School in Experimental Medicine, University of Pavia, Italy
| | - Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Federica Cipriani
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Rebecca Marino
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Raffaele Cerchione
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Marco Catena
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Michele Paganelli
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy.,Professor of Surgery, University Vita-Salute San Raffaele, Milan, Italy
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10
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Timing of Perioperative Chemotherapy Does Not Influence Long-Term Outcome of Patients Undergoing Combined Laparoscopic Colorectal and Liver Resection in Selected Upfront Resectable Synchronous Liver Metastases. World J Surg 2020; 43:3110-3119. [PMID: 31451846 DOI: 10.1007/s00268-019-05142-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study was to compare patients undergoing combined colorectal and hepatic surgery with and without neoadjuvant chemotherapy to clarify the prognostic advantage of preoperative oncological treatment in a case-matched analysis using propensity scores and to identify factors predictive of good prognosis in a selected population of Synchronous ColoRectal Liver Metastases (SCRLM). METHODS A total of 73 patients who underwent upfront elective combined surgery without preoperative CT for SCRLM in two European tertiary referral centers were selected and constituted the study group (NoNACT group). The NoNACT group was matched (ratio 1:1) with patients who were operated after chemotherapy with neoadjuvant intent (NACT group, the control group). The matching was achieved based on six covariates representative of patients and disease characteristics. RESULTS While the characteristics of both colorectal and hepatic procedures were similar, the NoNACT group, as compared to the NACT group, had lower blood loss (200 mL vs. 550 mL). Postoperative stay (9 vs. 12 days) and morbidity rate (24.7% vs. 32.9%) were reduced in the NoNACT compared with the NACT group. Mid- and long-term outcomes were comparable. At multivariable analysis, predictors of long-term outcome were: right colonic neoplasms, RAS mutational status, CRS score ≥3 and the absence of perioperative chemotherapy. CONCLUSION Preoperative neoadjuvant chemotherapy in patients with colorectal cancer and synchronous resectable liver metastases does not influence the risk of recurrence in patients with favorable tumor biology, while it was associated with increased intraoperative blood loss and morbidity. There is no strong evidence to recommend upfront chemotherapy in the absence of negative prognostic factors.
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11
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Fung AKY, Chong CCN, Lai PBS. ERAS in minimally invasive hepatectomy. Ann Hepatobiliary Pancreat Surg 2020; 24:119-126. [PMID: 32457255 PMCID: PMC7271107 DOI: 10.14701/ahbps.2020.24.2.119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/23/2020] [Accepted: 01/29/2020] [Indexed: 02/07/2023] Open
Abstract
Open hepatectomy is associated with significant post-operative morbidity and mortality profile. The use of minimally invasive approach for hepatectomy can reduce the post-operative complication profile and total length of hospital stay. Enhanced recovery after surgery (ERAS) programs involve evidence-based multimodal care pathways designed to achieve early recovery for patients undergoing major surgery. This review will discuss the published evidence, challenges and future directions for ERAS in minimally invasive hepatectomy.
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Affiliation(s)
- Andrew K Y Fung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Charing C N Chong
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Paul B S Lai
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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Ratti F, Cipriani F, Fiorentini G, Catena M, Paganelli M, Aldrighetti L. Reappraisal of the advantages of laparoscopic liver resection for intermediate hepatocellular carcinoma within a stage migration perspective: Propensity score analysis of the differential benefit. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:510-521. [PMID: 32189450 DOI: 10.1002/jhbp.736] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/02/2020] [Accepted: 03/15/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The aim of the present study was to analyze the outcome of laparoscopic approach specifically in patients with Intermediate-stage disease and to define the differential benefit with Early-stage patients. METHODS Six hundred twenty-two resections for HCC were dichotomized according to staging (Early and Intermediate) and to approach and then matched in a 1:1 ratio using propensity scores to obtain four groups (E-MILS and E-Open, including 104 patients respectively; Int-MILS and Int-Open, including 142 patients, respectively). The differential benefit associated with the minimally invasive technique was evaluated between intermediate-stage and early-stage patients taking into account blood loss and morbidity rate as outcome indicators. RESULTS Laparoscopic approach resulted in a statistically significant lower blood loss, reduced morbidity, reduced incidence of hepatic decompensation and shorter time for functional recover and length of stay. The evaluation of the differential benefit showed a greater advantage of laparoscopic approach in Intermediate-stage patients compared with Early-stage patients, both in terms of blood loss and morbidity rate. CONCLUSIONS The favorable biological scenario associated with laparoscopic approach allows to obtain enhanced benefits in the setting of more advanced liver disease. The push towards minimal invasiveness and the incremental benefit associated with it could potentially promote stage migration in suitable patients.
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Affiliation(s)
- Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy
| | - Federica Cipriani
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy
| | - Guido Fiorentini
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy
| | - Marco Catena
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy
| | - Michele Paganelli
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy
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Cipriani F, Ratti F, Paganelli M, Reineke R, Catena M, Aldrighetti L. Laparoscopic or open approaches for posterosuperior and anterolateral liver resections? A propensity score based analysis of the degree of advantage. HPB (Oxford) 2019; 21:1676-1686. [PMID: 31208900 DOI: 10.1016/j.hpb.2019.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 03/29/2019] [Accepted: 05/10/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Benefits over the open technique are demonstrated for laparoscopic liver resections. Whether the degree of advantage is different for anterolateral and posterosuperior resections is investigated in this retrospective study. METHODS Laparoscopic anterolateral and posterosuperior resections (Lap-AL/Lap-PS) were compared with open (Open-AL/Open-PS) after propensity score matching. Mean/median differences of relevant parameters were calculated after bootstrap sampling. The degree of advantage was compared between anterolateral and posterosuperior resections and expressed as delta of differences (Δ-difference). RESULTS 239 Lap-AL were compared with 239 matched Open-AL, and 176 Lap-PS with 176 matched Open-PS. Lap-AL showed reduced blood loss, morbidity, time to orally-controlled pain, mobilization and total stay; Lap-PS showed reduced blood loss, transfusions, morbidity, time to orally-controlled pain, mobilization, functional recovery and total stay. The degree of advantage of Lap-PS resulted significantly greater than Lap-AL blood loss (Δ-difference: 101 mL, p 0.017), transfusions (Δ-difference: 6.3%, p 0.008), morbidity (Δ-difference: 7.6%, p 0.034), time to orally-controlled pain (Δ-difference: 1 day, p 0.020) and functional recovery (Δ-difference: 1 day, p 0.042). CONCLUSIONS While both resulting in benefit, the advantage of laparoscopy is greater for posterosuperior than anterolateral resections. Despite their technical difficulty, these should be considered among the most worthwhile laparoscopic liver resections.
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Affiliation(s)
- Federica Cipriani
- Hepatobiliary Surgery Division, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy.
| | - Francesca Ratti
- Hepatobiliary Surgery Division, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Michele Paganelli
- Hepatobiliary Surgery Division, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Raffaella Reineke
- Anaesthesiology and Intensive Care Unit, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Marco Catena
- Hepatobiliary Surgery Division, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
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Ratti F, Serenari M, Zanello M, Prosperi E, Cipriani F, Ercolani G, Jovine E, Cescon M, Aldrighetti L. Appraisal of disease-specific benefits of minimally invasiveness in surgery of breast cancer liver metastases. J Surg Oncol 2019; 120:1169-1176. [PMID: 31502270 DOI: 10.1002/jso.25702] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 08/26/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND The primary endpoint of this study is to analyze short term benefit of laparoscopic approach (minimally invasive liver surgery [MILS]) over the open techniques in patients submitted to surgery for breast cancer liver metastases (BCLM) within a disease-specific perspective. MATERIAL AND METHODS A group of 30 patients who underwent laparoscopic liver resection for BCLM constituted the Study group (MILS group) and was matched in a ratio of 1:2 with patients who underwent open surgery for BCLM (Open group, constituting the Control group). RESULTS MILS approach resulted in a statistically significant lower blood loss (150 vs 300 mL; P < .05). The rate of postoperative complications was similar (13.3% and 16.6% in the MILS and Open groups, respectively). MILS approach was associated with a shorter length of postoperative stay (4 ± 2 days) compared with the Open group (7 ± 3 days), allowing a faster return to adjuvant treatments. Both MILS and open groups showed adequate oncological radicality, with comparable long-term results. CONCLUSION MILS approach to BCLM represents the optimal instrument to obtain an adequate disease clearance in the selected group of patients candidates to surgery: the type of procedure (minor resections for limited hepatic disease) and characteristics of patients contribute to enhance the feasibility and the benefits of the laparoscopic technique.
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Affiliation(s)
- Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy
| | - Matteo Serenari
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Matteo Zanello
- Department of General Surgery, Maggiore Hospital, Bologna, Italy
| | - Enrico Prosperi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Federica Cipriani
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy
| | - Giorgio Ercolani
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Elio Jovine
- Department of General Surgery, Maggiore Hospital, Bologna, Italy
| | - Matteo Cescon
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy
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Aldrighetti L, Cipriani F, Fiorentini G, Catena M, Paganelli M, Ratti F. A stepwise learning curve to define the standard for technical improvement in laparoscopic liver resections: complexity-based analysis in 1032 procedures. Updates Surg 2019; 71:273-283. [PMID: 31119579 DOI: 10.1007/s13304-019-00658-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 04/29/2019] [Indexed: 02/07/2023]
Abstract
The objective of this study is to define the learning curve in a series of procedures grouped according to their complexity calculated by difficulty index to define a standard for technical improvement. 1032 laparoscopic liver resections performed in a single tertiary referral center were stratified by difficulty scores: low difficulty (LD, n = 362); intermediate difficulty (ID, n = 332), and high difficulty (HD, n = 338). The learning curve effect was analyzed using the cumulative sum (CUSUM) method taking into consideration the expected risk of conversion. The ratio of laparoscopic/total liver resections increased from 5.8% (2005) to 71.1% (2018). The CUSUM analysis per group showed that the average value of the conversion rate was reached at the 60th case in the LD Group and at the 15th in the ID and HD groups. The evolution from LD to ID and HD procedures occurred only when learning curve in LD resections was concluded. Reflecting different degree of complexity, procedures showed significantly different blood loss, morbidity, and conversions among groups. A standard educational model-stepwise and progressive-is mandatory to allow surgeons to define the technical and technological backgrounds to deal with a specific degree of difficulty, providing a help in the definition of indications to laparoscopic approach in each phase of training.
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Affiliation(s)
- Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy.
| | - Federica Cipriani
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
| | - Guido Fiorentini
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
| | - Marco Catena
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
| | - Michele Paganelli
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
| | - Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
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Zhou SY, Shen HP, Zhang GL, Sun C. Impact of fast track surgery on inflammatory factors, gastrointestinal hormones, and gastrointestinal function in patients undergoing hepatobiliary surgery. Shijie Huaren Xiaohua Zazhi 2019; 27:305-310. [DOI: 10.11569/wcjd.v27.i5.305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hepatobiliary surgery, due to complex physiological and anatomical structures, is difficult and risky, and patients often have a strong stress reaction, which will affect the smooth operation and postoperative rehabilitation. Fast track surgery can strengthen perioperative process management by using various effective measures confirmed by evidence-based medicine, and its application in hepatobiliary surgery is worthy of affirmation. However, there are few studies reporting inflammatory factors and gastrointestinal hormones in patients undergoing hepatobiliary surgery using a fast track surgery program.
AIM To study the effect of fast track surgery on inflammatory factors, gastrointestinal hormones, and gastrointestinal function in patients undergoing hepatobiliary surgery.
METHODS A total of 126 patients undergoing hepatobiliary surgery from May 2017 to April 2018 were divided into an intervention group and a control group. The control group was given conventional surgical management, and the intervention group given was given fast track surgery management. Serum inflammatory factors, gastrointestinal hormones, gastrointestinal function recovery time, and complications were compared between the two groups.
RESULTS Serum tumor necrosis factor-α, C reactive protein, and interleukin-6 were significantly lower in the intervention group than in the control group (36.20 pg/mL ± 5.32 pg/mL vs 43.55 pg/mL ± 6.12 pg/mL, 12.42 mg/L ± 2.35 mg/L vs 18.65 mg/L ± 3.24 mg/L, 10.24 pg/L ± 2.10 pg/L vs 15.04 pg/L ± 2.32 pg/L; t = 7.194, 12.355, 12.175; P < 0.05 or P < 0.01). Serum motilin and gastrin were significantly higher in the intervention group than in the control group (205.45 pg/mL ± 25.16 pg/mL vs 168.24 pg/mL ± 24.25 pg/mL, 124.32 pg/mL ± 24.15 pg/mL vs 104.36 pg/mL ± 20.42 pg/mL; t = 8.452, 5.009; P < 0.05, P < 0.01). Time to recovery of bowel sounds, time to anal exhaust, time to first defecation, and postoperative hospital stay were significantly shorter in the intervention group than in the control group [16.45 h ± 3.12 h vs 21.24 h ± 3.65 h, 20.34 h ± 4.54 h vs 41.25 h ± 6.12 h, 38.65 h ± 5.24 h vs 57.42 h ± 7.15 h, 9.21 d ± 1.32 d vs 13.54 d ± 2.12 d; t = 7.918, 21.780, 18.607, 13.762; P < 0.05 or P < 0.01). The rate of complications such as incision infection was significantly lower in the intervention group than in the control group (9.52% vs 26.98%, χ2 = 6.436, P < 0.05).
CONCLUSION Fast track surgery can promote gastrointestinal function recovery and reduce complications in patients undergoing hepatobiliary surgery, which may be related to inhibiting inflammatory response and regulating gastrointestinal hormones.
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Affiliation(s)
- Shi-Yu Zhou
- Department of General Surgery, Huzhou Central Hospital, Huzhou 313000, Zhejiang Province, China
| | - Hua-Ping Shen
- Department of General Surgery, Huzhou Central Hospital, Huzhou 313000, Zhejiang Province, China
| | - Guo-Lei Zhang
- Department of General Surgery, Huzhou Central Hospital, Huzhou 313000, Zhejiang Province, China
| | - Cheng Sun
- Department of General Surgery, Huzhou Central Hospital, Huzhou 313000, Zhejiang Province, China
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