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Andraus W, Tustumi F, Santana AC, Pinheiro RSN, Waisberg DR, Lopes LD, Arantes RM, Santos VR, de Martino RB, D'Albuquerque LAC. Liver transplantation as an alternative for the treatment of perihilar cholangiocarcinoma: A critical review. Hepatobiliary Pancreat Dis Int 2024; 23:139-145. [PMID: 38310060 DOI: 10.1016/j.hbpd.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 01/19/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND Perihilar cholangiocarcinoma (phCCC) is a dismal malignancy. There is no consensus regarding the best treatment for patients with unresectable phCCC. The present review aimed to gather the current pieces of evidence for liver transplantation and liver resection as a treatment for phCCC and to build better guidance for clinical practice. DATA SOURCES The search was conducted in PubMed, Embase, Cochrane, and LILACS. The related references were searched manually. Inclusion criteria were: reports in English or Portuguese literature that a) patients with confirmed diagnosis of phCCC; b) patients treated with a curative intent; c) patients with the outcomes of liver resection and liver transplantation. Case reports, reviews, letters, editorials, conference abstracts and papers with full-text unavailability were excluded from the analysis. RESULTS Most of the current literature is based on observational retrospective studies with low grades of evidence. Liver resection has better long-term outcomes than systemic chemotherapy or palliation therapy and liver transplantation is a good alternative for selected patients with unresectable phCCC. All candidates for resection or transplantation should be medically fit and free of intrahepatic or extrahepatic diseases. As a general rule, patients presenting with a tumor having a longitudinal size > 3 cm or extending below the cystic duct, lymph node disease, confirmed extrahepatic dissemination; intraoperatively diagnosed metastatic disease; a history of other malignancies within the last five years, and did not complete chemoradiation regimen and were medically unfit should not be considered for transplantation. Some of these criteria should be individually assessed. Liver transplantation or resection should only be considered in highly experienced hepatobiliary centers, and any decision-making must be based on a multidisciplinary evaluation. CONCLUSIONS phCCC is a complex condition with high morbidity. Surgical therapies, including hepatectomy and liver transplantation, are the best option for better long-term disease-free survival.
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Affiliation(s)
- Wellington Andraus
- Department of Gastroenterology, Transplantation Unit, Universidade de São Paulo, São Paulo, Brazil.
| | - Francisco Tustumi
- Department of Gastroenterology, Transplantation Unit, Universidade de São Paulo, São Paulo, Brazil
| | - Alexandre Chagas Santana
- Department of Gastroenterology, Transplantation Unit, Universidade de São Paulo, São Paulo, Brazil
| | | | - Daniel Reis Waisberg
- Department of Gastroenterology, Transplantation Unit, Universidade de São Paulo, São Paulo, Brazil
| | - Liliana Ducatti Lopes
- Department of Gastroenterology, Transplantation Unit, Universidade de São Paulo, São Paulo, Brazil
| | - Rubens Macedo Arantes
- Department of Gastroenterology, Transplantation Unit, Universidade de São Paulo, São Paulo, Brazil
| | - Vinicius Rocha Santos
- Department of Gastroenterology, Transplantation Unit, Universidade de São Paulo, São Paulo, Brazil
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2
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Suydam CR, Aranda MC, O'Hara TA, Kobylarz FC, Liang JN, Bandera B. Practice patterns of hepatobiliary surgery within the military. Surg Endosc 2023; 37:7502-7510. [PMID: 37415016 PMCID: PMC10520085 DOI: 10.1007/s00464-023-10150-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/20/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND The purpose of this study is to evaluate the trends of hepatobiliary surgeries performed at military hospitals and to discuss potential implications on resident training and military readiness. While there is data to suggest centralization of surgical specialty services leads to improved patient outcomes, the military does not currently have a specific centralization policy. Implementation of such a policy could potentially impact resident training and readiness of military surgeons. Even in the absence of such a policy, there may still be a trend toward centralization of more complex surgeries like hepatobiliary surgeries. The present study evaluates the numbers and types of hepatobiliary procedures performed at military hospitals. METHODS This study is a retrospective review of de-identified data from Military Health System Mart (M2) from 2014 to 2020. The M2 database contains patient data from all Defense Health Agency treatment facilities, encompassing all branches of the United States Military. Variables collected include number and types of hepatobiliary procedures performed and patient demographics. The primary endpoint was the number and type of surgery for each medical facility. Linear regression was used to evaluate significant trends in numbers of surgeries over time. RESULTS Fifty-five military hospitals performed hepatobiliary surgeries from 2014 to 2020. A total of 1,087 hepatobiliary surgeries were performed during this time; cholecystectomies, percutaneous procedures, and endoscopic procedures were excluded. There was no significant decrease in overall case volume. The most commonly performed hepatobiliary surgery was "unlisted laparoscopic liver procedure." The military training facility with the most hepatobiliary cases was Brooke Army Medical Center. CONCLUSION The number of hepatobiliary surgeries performed in military hospitals has not significantly decreased over the years 2014-2020, despite a national trend toward centralization. Centralization of hepatobiliary surgeries in the future may impact residency training as well as military medical readiness.
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Affiliation(s)
- Camille R Suydam
- Department of Surgery, Eisenhower Army Medical Center, Fort Gordon, USA.
| | - Marcos C Aranda
- Department of Surgery, Eisenhower Army Medical Center, Fort Gordon, USA
| | - Thomas A O'Hara
- Department of Surgery, Eisenhower Army Medical Center, Fort Gordon, USA
| | - Fred C Kobylarz
- Department of Surgery, Eisenhower Army Medical Center, Fort Gordon, USA
| | - Joy N Liang
- Department of Surgery, Eisenhower Army Medical Center, Fort Gordon, USA
| | - Bradley Bandera
- Department of Surgery, Eisenhower Army Medical Center, Fort Gordon, USA
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3
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Guglielmi A, Tripepi M, Salmaso L, Fedeli U, Ruzzenente A, Saia M. Trends in hospital volume and operative mortality in hepato-biliary surgery in Veneto region, Italy. Updates Surg 2023; 75:1949-1959. [PMID: 37395932 PMCID: PMC10543584 DOI: 10.1007/s13304-023-01574-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/22/2023] [Indexed: 07/04/2023]
Abstract
Hepatobiliary resections are among the most complex and technically challenging surgical procedures. Even though robust evidence showed that complex surgical procedures such as hepatobiliary surgery have better short- and long-term outcomes and lower mortality rate when performed in high-volume centers, the minimal criteria of centers that can perform hepatobiliary activity are not clearly defined. We conducted a retrospective population study of patients who underwent hepatobiliary surgery for malignant disease in a single Italian administrative region (Veneto) from 2010 to 2021 with the aim to investigate the hospitals annual surgical volume for hepatobiliary malignant diseases and the effect of hospital volume on in-hospital, 30- and 90-day postoperative mortality. The centralization process of hepatobiliary surgery in Veneto is rapidly increasing over the past 10 years (rate of performed in highly specialized centers increased from 62% in 2010 to 78% in 2021) and actually it is really established. The crude and adjusted (for age, sex, Charlson Index) mortality rate after hepatobiliary surgery resulted significantly lower in centers with high-volume activity compared to them with low-volume activity. In the Veneto region, the "Hub and Spoke" model led to a progressive centralization of liver and biliary cancer treatment. High surgical volume has been confirmed to be related to better outcomes in terms of mortality rate after hepatobiliary surgical procedures. Further studies are necessary to clearly define the minimal criteria and associated numerical cutoffs that can help define the characteristics of centers that can perform hepatobiliary activities.
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Affiliation(s)
- Alfredo Guglielmi
- Department of Surgery, Division of General and Hepatobiliary Surgery, School of Medicine, University of Verona, Piazzale L. Scuro, 10, 37123, Verona, Italy
| | - Marzia Tripepi
- Department of Surgery, Division of General and Hepatobiliary Surgery, School of Medicine, University of Verona, Piazzale L. Scuro, 10, 37123, Verona, Italy
| | | | - Ugo Fedeli
- Azienda Zero, Veneto Region, Padua, Italy
| | - Andrea Ruzzenente
- Department of Surgery, Division of General and Hepatobiliary Surgery, School of Medicine, University of Verona, Piazzale L. Scuro, 10, 37123, Verona, Italy.
| | - Mario Saia
- Azienda Zero, Veneto Region, Padua, Italy
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4
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Neary C, O'Brien L, McCormack E, Kelly M, Bolger J, McEntee G, Conneely J. Defining a textbook outcome for the resection of colorectal liver metastases. J Surg Oncol 2023; 127:616-624. [PMID: 36541290 DOI: 10.1002/jso.27170] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 11/09/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Textbook outcomes (TBO) are composite measures of care which may be superior in assessing quality compared to traditional methods. We aim to define TBO which are specific to surgical resection of colorectal liver metastases, and investigate their impact on survival. METHODS Single center analysis of all liver resections performed at our center from 2009 to 2020. A Cox model was used to identify perioperative outcomes which impacted on overall survival. These were retained with important postoperative outcomes to form a "TBO." The impact of a TBO on overall survival was investigated using Kaplan-Meier curve analysis. RESULTS TBO was achieved in 72.2% (197/273) of resections. Major morbidity (Clavien-Dindo ≥3) at 19.4% was the major limiting factor in not achieving a TBO. TBO was associated with improved 3-year (77% vs. 55%), 5-year (60.7% vs. 42.5%), and median (93 vs. 44 months) overall survival (log-rank test, p = 0.006). Multivariable analysis revealed age >65 years, American Society of Anaesthesiologists Grade III-IV, and resection of >2 segments as factors predictive of not achieving a TBO. CONCLUSION TBO is a useful composite measure in surgery for colorectal liver metastases. It can highlight areas which may be targeted for quality improvement and be useful as a tool to examine variation between centers. Achieving a TBO is associated with a significant improvement in survival.
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Affiliation(s)
- Colm Neary
- Department of Hepatobiliary Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Lukas O'Brien
- Department of Hepatobiliary Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Emilie McCormack
- Department of Hepatobiliary Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Michael Kelly
- Department of Hepatobiliary Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Jarlath Bolger
- Department of Hepatobiliary Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Gerard McEntee
- Department of Hepatobiliary Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - John Conneely
- Department of Hepatobiliary Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
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5
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Magnin J, Bernard A, Cottenet J, Lequeu JB, Ortega-Deballon P, Quantin C, Facy O. Impact of hospital volume in liver surgery on postoperative mortality and morbidity: nationwide study. Br J Surg 2023; 110:441-448. [PMID: 36724824 DOI: 10.1093/bjs/znac458] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 11/17/2022] [Accepted: 12/13/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND This nationwide retrospective study was undertaken to evaluate impact of hospital volume and influence of liver transplantation activity on postoperative mortality and failure to rescue after liver surgery. METHODS This was a retrospective study of patients who underwent liver resection between 2011 and 2019 using a nationwide database. A threshold of surgical activities from which in-hospital mortality declines was calculated. Hospitals were divided into high- and low-volume centres. Main outcomes were in-hospital mortality and failure to rescue. RESULTS Among 39 286 patients included, the in-hospital mortality rate was 2.8 per cent. The activity volume threshold from which in-hospital mortality declined was 25 hepatectomies. High-volume centres (more than 25 resections per year) had more postoperative complications but a lower rate of in-hospital mortality (2.6 versus 3 per cent; P < 0.001) and failure to rescue (5 versus 6.3 per cent; P < 0.001), in particular related to specific complications (liver failure, biliary complications, vascular complications) (5.5 versus 7.6 per cent; P < 0.001). Liver transplantation activity did not have an impact on these outcomes. CONCLUSION From more than 25 liver resections per year, rates of in-hospital mortality and failure to rescue declined. Management of specific postoperative complications appeared to be better in high-volume centres.
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Affiliation(s)
- Josephine Magnin
- Department of Digestive Surgical Oncology, University Hospital of Dijon, Dijon, France
| | - Alain Bernard
- Clinical Epidemiology/Clinical Trials Unit, Clinical Investigation Centre, University Hospital of Dijon, Dijon, France.,Department of Thoracic and Cardiovascular Surgery, University Hospital of Dijon, Dijon, France
| | - Jonathan Cottenet
- Clinical Epidemiology/Clinical Trials Unit, Clinical Investigation Centre, University Hospital of Dijon, Dijon, France
| | - Jean-Baptiste Lequeu
- Department of Digestive Surgical Oncology, University Hospital of Dijon, Dijon, France
| | - Pablo Ortega-Deballon
- Department of Digestive Surgical Oncology, University Hospital of Dijon, Dijon, France
| | - Catherine Quantin
- Clinical Epidemiology/Clinical Trials Unit, Clinical Investigation Centre, University Hospital of Dijon, Dijon, France
| | - Olivier Facy
- Department of Digestive Surgical Oncology, University Hospital of Dijon, Dijon, France
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6
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de’Angelis N, Marchegiani F, Schena CA, Khan J, Agnoletti V, Ansaloni L, Barría Rodríguez AG, Bianchi PP, Biffl W, Bravi F, Ceccarelli G, Ceresoli M, Chiara O, Chirica M, Cobianchi L, Coccolini F, Coimbra R, Cotsoglou C, D’Hondt M, Damaskos D, De Simone B, Di Saverio S, Diana M, Espin‐Basany E, Fichtner‐Feigl S, Fugazzola P, Gavriilidis P, Gronnier C, Kashuk J, Kirkpatrick AW, Ammendola M, Kouwenhoven EA, Laurent A, Leppaniemi A, Lesurtel M, Memeo R, Milone M, Moore E, Pararas N, Peitzmann A, Pessaux P, Picetti E, Pikoulis M, Pisano M, Ris F, Robison T, Sartelli M, Shelat VG, Spinoglio G, Sugrue M, Tan E, Van Eetvelde E, Kluger Y, Weber D, Catena F. Training curriculum in minimally invasive emergency digestive surgery: 2022 WSES position paper. World J Emerg Surg 2023; 18:11. [PMID: 36707879 PMCID: PMC9883976 DOI: 10.1186/s13017-023-00476-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/09/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Minimally invasive surgery (MIS), including laparoscopic and robotic approaches, is widely adopted in elective digestive surgery, but selectively used for surgical emergencies. The present position paper summarizes the available evidence concerning the learning curve to achieve proficiency in emergency MIS and provides five expert opinion statements, which may form the basis for developing standardized curricula and training programs in emergency MIS. METHODS This position paper was conducted according to the World Society of Emergency Surgery methodology. A steering committee and an international expert panel were involved in the critical appraisal of the literature and the development of the consensus statements. RESULTS Thirteen studies regarding the learning curve in emergency MIS were selected. All but one study considered laparoscopic appendectomy. Only one study reported on emergency robotic surgery. In most of the studies, proficiency was achieved after an average of 30 procedures (range: 20-107) depending on the initial surgeon's experience. High heterogeneity was noted in the way the learning curve was assessed. The experts claim that further studies investigating learning curve processes in emergency MIS are needed. The emergency surgeon curriculum should include a progressive and adequate training based on simulation, supervised clinical practice (proctoring), and surgical fellowships. The results should be evaluated by adopting a credentialing system to ensure quality standards. Surgical proficiency should be maintained with a minimum caseload and constantly evaluated. Moreover, the training process should involve the entire surgical team to facilitate the surgeon's proficiency. CONCLUSIONS Limited evidence exists concerning the learning process in laparoscopic and robotic emergency surgery. The proposed statements should be seen as a preliminary guide for the surgical community while stressing the need for further research.
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Affiliation(s)
- Nicola de’Angelis
- grid.508487.60000 0004 7885 7602Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, Paris, France ,grid.410511.00000 0001 2149 7878Faculty of Medicine, University of Paris Est, UPEC, Créteil, France
| | - Francesco Marchegiani
- grid.508487.60000 0004 7885 7602Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, Paris, France
| | - Carlo Alberto Schena
- grid.508487.60000 0004 7885 7602Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, Paris, France
| | - Jim Khan
- grid.4701.20000 0001 0728 6636Department of Colorectal Surgery, Queen Alexandra Hospital, University of Portsmouth, Southwick Hill Road, Cosham, Portsmouth, UK
| | - Vanni Agnoletti
- grid.414682.d0000 0004 1758 8744Intensive Care Unit, Bufalini Hospital, Cesena, Italy
| | - Luca Ansaloni
- grid.419425.f0000 0004 1760 3027Department of General Surgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | | | - Paolo Pietro Bianchi
- grid.4708.b0000 0004 1757 2822Division of General and Robotic Surgery, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
| | - Walter Biffl
- grid.415402.60000 0004 0449 3295Division of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA USA
| | - Francesca Bravi
- grid.415207.50000 0004 1760 3756Healthcare Administration, Santa Maria Delle Croci Hospital, Ravenna, Italy
| | - Graziano Ceccarelli
- General Surgery, San Giovanni Battista Hospital, USL Umbria 2, Foligno, Italy
| | - Marco Ceresoli
- grid.7563.70000 0001 2174 1754General and Emergency Surgery, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Osvaldo Chiara
- grid.4708.b0000 0004 1757 2822General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Mircea Chirica
- grid.450307.50000 0001 0944 2786Department of Digestive Surgery and Liver Transplantation, Michallon Hospital, Grenoble University, Grenoble, France
| | - Lorenzo Cobianchi
- grid.419425.f0000 0004 1760 3027Department of General Surgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy ,grid.8982.b0000 0004 1762 5736Department of Clinical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Federico Coccolini
- grid.144189.10000 0004 1756 8209General, Emergency and Trauma Department, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- grid.488519.90000 0004 5946 0028Riverside University Health System Medical Center, Riverside, CA USA
| | | | - Mathieu D’Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Dimitris Damaskos
- grid.418716.d0000 0001 0709 1919Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint‐Germain‐en‐Laye Hospitals, Poissy, France
| | - Salomone Di Saverio
- Unit of General Surgery, San Benedetto del Tronto Hospital, av5 Asur Marche, San Benedetto del Tronto, Italy
| | - Michele Diana
- grid.11843.3f0000 0001 2157 9291Digestive and Endocrine Surgery, Nouvel Hôpital Civil, University of Strasbourg, Strasbourg, France ,grid.420397.b0000 0000 9635 7370IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
| | - Eloy Espin‐Basany
- grid.7080.f0000 0001 2296 0625Department of General Surgery, Hospital Valle de Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Stefan Fichtner‐Feigl
- grid.7708.80000 0000 9428 7911Department of General and Visceral Surgery, Medical Center University of Freiburg, Freiburg, Germany
| | - Paola Fugazzola
- grid.419425.f0000 0004 1760 3027Department of General Surgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Paschalis Gavriilidis
- grid.15628.380000 0004 0393 1193Department of HBP Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX UK
| | - Caroline Gronnier
- grid.42399.350000 0004 0593 7118Eso-Gastric Surgery Unit, Department of Digestive Surgery, Magellan Center, Bordeaux University Hospital, Pessac, France
| | - Jeffry Kashuk
- grid.12136.370000 0004 1937 0546Department of Surgery, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Andrew W. Kirkpatrick
- grid.414959.40000 0004 0469 2139Department of General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB Canada
| | - Michele Ammendola
- grid.411489.10000 0001 2168 2547Digestive Surgery Unit, Health of Science Department, “Magna Graecia” University Medical School, “Mater Domini” Hospital, Catanzaro, Italy
| | - Ewout A. Kouwenhoven
- grid.417370.60000 0004 0502 0983Department of Surgery, Hospital Group Twente ZGT, Almelo, Netherlands
| | - Alexis Laurent
- grid.410511.00000 0001 2149 7878Faculty of Medicine, University of Paris Est, UPEC, Créteil, France ,grid.412116.10000 0004 1799 3934Unit of HPB and Service of General Surgery, Henri Mondor University Hospital, Creteil, France
| | - Ari Leppaniemi
- grid.7737.40000 0004 0410 2071Department of Gastrointestinal Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mickaël Lesurtel
- grid.508487.60000 0004 7885 7602Department of HPB Surgery and Liver Transplantation, AP-HP Beaujon Hospital, University of Paris Cité, Clichy, France
| | - Riccardo Memeo
- grid.415844.80000 0004 1759 7181Unit of Hepato‐Pancreato‐Biliary Surgery, General Regional Hospital “F. Miulli”, Acquaviva delle Fonti, Bari, Italy
| | - Marco Milone
- grid.4691.a0000 0001 0790 385XDepartment of Clinical Medicine and Surgery, Federico II” University of Naples, Naples, Italy
| | - Ernest Moore
- grid.241116.10000000107903411Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO USA
| | - Nikolaos Pararas
- grid.5216.00000 0001 2155 08003Rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Andrew Peitzmann
- grid.21925.3d0000 0004 1936 9000University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Patrick Pessaux
- grid.11843.3f0000 0001 2157 9291Visceral and Digestive Surgery, Nouvel Hôpital Civil, University of Strasbourg, Strasbourg, France ,grid.480511.9Institute for Image‐Guided Surgery, IHU Strasbourg, Strasbourg, France ,Institute of Viral and Liver Disease, INSERM U1110, Strasbourg, France
| | - Edoardo Picetti
- grid.411482.aDepartment of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | - Manos Pikoulis
- grid.5216.00000 0001 2155 08003Rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Michele Pisano
- 1St General Surgery Unit, Department of Emergency, ASST Papa Giovanni Hospital Bergamo, Bergamo, Italy
| | - Frederic Ris
- grid.150338.c0000 0001 0721 9812Division of Digestive Surgery, University Hospitals of Geneva and Medical School, Geneva, Switzerland
| | - Tyler Robison
- grid.5288.70000 0000 9758 5690Minimally Invasive Surgery Fellow, Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR USA
| | | | - Vishal G. Shelat
- grid.240988.f0000 0001 0298 8161Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Giuseppe Spinoglio
- grid.420397.b0000 0000 9635 7370IRCAD Faculty Member Robotic and Colorectal Surgery‐ IRCAD, Strasbourg, France
| | - Michael Sugrue
- grid.415900.90000 0004 0617 6488Department of Surgery, Letterkenny University Hospital, Donegal, Ireland
| | - Edward Tan
- grid.10417.330000 0004 0444 9382Department of Surgery, Trauma Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ellen Van Eetvelde
- grid.411326.30000 0004 0626 3362Department of Digestive Surgery, UZ, Brussels, Belgium
| | - Yoram Kluger
- Department of General Surgery, Rambam Healthcare Campus, Haifa, Israel
| | - Dieter Weber
- grid.416195.e0000 0004 0453 3875Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Fausto Catena
- grid.414682.d0000 0004 1758 8744Department of General and Emergency Surgery, Bufalini Hospital‐Level 1 Trauma Center, Cesena, Italy
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7
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Famularo S, Russolillo N, Donadon M, Cipriani F, Ardito F, Perri P, Giani A, De Stefano F, Lai Q, Molfino S, Zanello M, Iaria M, La Barba G, Pinotti E, Germani P, Conci S, Ferrari C, Fumagalli L, Romano M, Antonucci A, Zimmitti G, Troci A, Floridi A, Ferraro V, Patauner S, Frena A, Memeo R, Crespi M, Hilal MA, Zanus G, Chiarelli M, Percivale A, Ruzzenente A, Tarchi P, Zago M, Ercolani G, Dalla Valle R, Jovine E, Baiocchi GL, Rossi M, Maestri M, Romano F, Grazi GL, Giuliante F, Aldrighetti L, Ferrero A, Torzilli G. Benchmarking postoperative outcomes after open liver surgery for cirrhotic patients with hepatocellular carcinoma in a national cohort. HPB (Oxford) 2022; 24:1365-1375. [PMID: 35293320 DOI: 10.1016/j.hpb.2022.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/17/2022] [Accepted: 02/21/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Benchmark analysis for open liver surgery for cirrhotic patients with hepatocellular carcinoma (HCC) is still undefined. METHODS Patients were identified from the Italian national registry HE.RC.O.LE.S. The Achievable Benchmark of Care (ABC) method was employed to identify the benchmarks. The outcomes assessed were the rate of complications, major comorbidities, post-operative ascites (POA), post-hepatectomy liver failure (PHLF), 90-day mortality. Benchmarking was stratified for surgical complexity (CP1, CP2 and CP3). RESULTS A total of 978 of 2698 patients fulfilled the inclusion criteria. 431 (44.1%) patients were treated with CP1 procedures, 239 (24.4%) with CP2 and 308 (31.5%) with CP3 procedures. Patients submitted to CP1 had a worse underlying liver function, while the tumor burden was more severe in CP3 cases. The ABC for complications (13.1%, 19.2% and 28.1% for CP1, CP2 and CP3 respectively), major complications (7.6%, 11.1%, 12.5%) and 90-day mortality (0%, 3.3%, 3.6%) increased with the surgical difficulty, but not POA (4.4%, 3.3% and 2.6% respectively) and PHLF (0% for all groups). CONCLUSION We propose benchmarks for open liver resections in HCC cirrhotic patients, stratified for surgical complexity. The difference between the benchmark values and the results obtained during everyday practice reflects the room for potential growth, with the aim to encourage constant improvement among liver surgeons.
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Affiliation(s)
- Simone Famularo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Department of Hepatobiliary and General Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; School of Medicine and Surgery, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Nadia Russolillo
- Department of General and Oncological Surgery, Mauriziano Hospital "Umberto I", Turin, Italy
| | - Matteo Donadon
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Department of Hepatobiliary and General Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.
| | - Federica Cipriani
- Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Ardito
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Pasquale Perri
- Division of Hepatobiliarypancreatic Unit, IRCCS - Regina Elena National Cancer Institute, Rome, Italy
| | - Alessandro Giani
- School of Medicine and Surgery, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Francesca De Stefano
- Unit of General Surgery 1, University of Pavia and Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Quirino Lai
- Hepato-Biliary Surgery and Organ Transplantation Unit, Sapienza University of Rome, Umberto I Polyclinic of Rome, Rome, Italy
| | - Sarah Molfino
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Matteo Zanello
- Alma Mater Studiorum, University of Bologna, AOU Sant'Orsola Malpighi, IRCCS at Maggiore Hospital, Bologna, Italy
| | - Maurizio Iaria
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Giuliano La Barba
- General and Oncologic Surgery, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Enrico Pinotti
- Department of Surgery, Ponte San Pietro Hospital, Bergamo, Italy
| | - Paola Germani
- Surgical Clinics, University Hospital of Trieste, Trieste, Italy
| | - Simone Conci
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | | | - Luca Fumagalli
- Department of Emergency and Robotic Surgery, ASST Lecco, Lecco, Italy
| | - Maurizio Romano
- Department of Surgical, Oncological and Gastroenterological Science (DISCOG), University of Padua, Hepatobiliary and Pancreatic Surgery Unit - Treviso Hospital, Italy
| | | | - Giuseppe Zimmitti
- Department of General Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Albert Troci
- Department of Surgery, L. Sacco Hospital, Milan, Italy
| | | | - Valentina Ferraro
- Department of Hepato-Pancreatic-Biliary Surgery, Miulli Hospital, Bari, Italy
| | - Stefan Patauner
- Department of General and Pediatric Surgery, Bolzano Central Hospital, Bolzano, Italy
| | - Antonio Frena
- Department of General and Pediatric Surgery, Bolzano Central Hospital, Bolzano, Italy
| | - Riccardo Memeo
- Department of Hepato-Pancreatic-Biliary Surgery, Miulli Hospital, Bari, Italy
| | | | - Mohammed A Hilal
- Department of General Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Giacomo Zanus
- Department of Surgical, Oncological and Gastroenterological Science (DISCOG), University of Padua, Hepatobiliary and Pancreatic Surgery Unit - Treviso Hospital, Italy
| | - Marco Chiarelli
- Department of Emergency and Robotic Surgery, ASST Lecco, Lecco, Italy
| | | | - Andrea Ruzzenente
- Division of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Paola Tarchi
- Surgical Clinics, University Hospital of Trieste, Trieste, Italy
| | - Mauro Zago
- Department of Surgery, Ponte San Pietro Hospital, Bergamo, Italy; Department of Emergency and Robotic Surgery, ASST Lecco, Lecco, Italy
| | - Giorgio Ercolani
- General and Oncologic Surgery, Morgagni-Pierantoni Hospital, Forlì, Italy
| | | | - Elio Jovine
- Alma Mater Studiorum, University of Bologna, AOU Sant'Orsola Malpighi, IRCCS at Maggiore Hospital, Bologna, Italy
| | - Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Massimo Rossi
- Hepato-Biliary Surgery and Organ Transplantation Unit, Sapienza University of Rome, Umberto I Polyclinic of Rome, Rome, Italy
| | - Marcello Maestri
- Unit of General Surgery 1, University of Pavia and Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fabrizio Romano
- School of Medicine and Surgery, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Gian Luca Grazi
- Division of Hepatobiliarypancreatic Unit, IRCCS - Regina Elena National Cancer Institute, Rome, Italy
| | - Felice Giuliante
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Ferrero
- Department of General and Oncological Surgery, Mauriziano Hospital "Umberto I", Turin, Italy
| | - Guido Torzilli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Department of Hepatobiliary and General Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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8
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Azoulay D, Desterke C, Bhangui P, Salloum C, Conticchio M, Vibert E, Cherqui D, Adam R, Ichai P, Saliba F, Elmaleh A, Naili S, Lim C, Feray C. Tumors located in the central column of the liver are associated with increased surgical difficulty and postoperative complications following open liver resection for colorectal metastases. HPB (Oxford) 2022; 24:1376-1386. [PMID: 35437222 DOI: 10.1016/j.hpb.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/13/2022] [Accepted: 03/10/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND To assess the impact of difficult location (based on preoperative computed tomography) of liver metastases from colorectal cancer (LMCRC) on surgical difficulty, and occurrence of severe postoperative complications (POCs). METHODS A retrospective single-centre study of 911 consecutive patients with LMCRC who underwent hepatectomy by the open approach between 1998 and 2011, before implementation of laparoscopic surgery to obviate approach selection bias. LMCRC with at least one of the following four features on preoperative imaging: tumor invading the hepatocaval confluence or retro-hepatic inferior vena cava, centrally located (Segments 4,5,8) and >10 cm in diameter, abutting the supra-hilar area, or involving the paracaval portion or caudate process of Segment 1; were considered as topographically difficult (top-diff). Independent predictors of surgical difficulty assessed by number of blood units transfused, duration of ischemia, and number of sessions of pedicle clamping during surgery and of severe POCs were identified by multivariate analysis before, and after propensity score matching. RESULTS Top-diff tumor location independently predicted surgical difficulty. Severe POCs were associated with the tumor location [top-diff vs. topographically non difficult (non top-diff)], preoperative portal vein embolization, and variables related to surgical difficulty. CONCLUSION LMCRC in difficult location independently predicts surgical difficulty and severe POCs.
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Affiliation(s)
- Daniel Azoulay
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France; Institut National de La Santé et de La Recherche Médicale (INSERM) Unité 935, And Université Paris-Saclay, Villejuif, France.
| | - Christophe Desterke
- Université Paris-Saclay, Villejuif, France; Inserm UMR-S-MD A9, Hôpital Paul Brousse, Villejuif, France
| | - Prashant Bhangui
- Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India
| | - Chady Salloum
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France
| | - Maria Conticchio
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France
| | - Eric Vibert
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France; Institut National de La Santé et de La Recherche Médicale (INSERM) Unité 935, And Université Paris-Saclay, Villejuif, France
| | - Daniel Cherqui
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France; Institut National de La Santé et de La Recherche Médicale (INSERM) Unité 935, And Université Paris-Saclay, Villejuif, France
| | - René Adam
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France; Institut National de La Santé et de La Recherche Médicale (INSERM) Unité 935, And Université Paris-Saclay, Villejuif, France
| | - Philippe Ichai
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France
| | - Faouzi Saliba
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France
| | - Annie Elmaleh
- Service de Radiologie, Assistance Publique-Hôpitaux de Paris, Hôpital Paul Brousse, Villejuif, France
| | - Salima Naili
- Département D'Anesthésie-Réanimation, Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France
| | - Chetana Lim
- Département de Chirurgie Hépato-Biliaire et Transplantation Hépatique, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Pitié-Salpêtrière, Paris, France
| | - Cyrille Feray
- Centre Hépato-Biliaire, Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, France; Institut National de La Santé et de La Recherche Médicale (INSERM) Unité 935, And Université Paris-Saclay, Villejuif, France
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9
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Shi HY, Lee KT, Chiu CC, Wang JJ, Sun DP, Lee HH. 5-year recurrence prediction after hepatocellular carcinoma resection: deep learning vs. Cox regression models. Am J Cancer Res 2022; 12:2876-2890. [PMID: 35812048 PMCID: PMC9251698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/30/2022] [Indexed: 06/15/2023] Open
Abstract
Deep learning algorithms have yet to be used for predicting clinical prognosis after cancer surgery. Therefore, this study compared performance indices and permutation importance of potential confounders in three models for predicting 5-year recurrence after hepatocellular carcinoma (HCC) resection: a deep-learning deep neural network (DNN) model, a recurrent neural network (RNN) model, and a Cox proportional hazard (CPH) regression model. Data for 725 patients who had received HCC resection at three medical centers in southern Taiwan between April, 2011, and December, 2015, were randomly divided into three datasets: a training dataset containing data for 507 subjects was used for model development, a testing dataset containing data for 109 subjects was used for internal validation, and a validating dataset containing data for 109 subjects was used for external validation. Feature importance analysis was also performed to identify potential predictors of recurrence after HCC resection. Univariate Cox proportional hazards regression analyses were performed to identify potential significant predictors of 5-year recurrence after HCC resection, which were included in the forecasting models (P < 0.05). All performance indices for the DNN model were significantly higher than those for the RNN model and the conventional CPH model (P < 0.001). The most important potential predictor of 5-year recurrence after HCC resection was surgeon volume followed by, in order of importance, hospital volume, preoperative Beck Depression Scale score, preoperative Beck Anxiety Scale score, co-residence with family, tumor stage, and tumor size. The feature importance analysis performed to investigate interpretability in this study elucidated the potential use of deep learning models for predicting recurrence after HCC resection and for identifying predictors of recurrence. Further experiments using the proposed DNN model would clarify its potential uses for developing, promoting, and improving health policies for treating HCC patients after surgery.
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Affiliation(s)
- Hon-Yi Shi
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical UniversityKaohsiung 80708, Taiwan
- Department of Business Management, National Sun Yat-sen UniversityKaohsiung 80420, Taiwan
- Department of Medical Research, Kaohsiung Medical University HospitalKaohsiung 80708, Taiwan
- Department of Medical Research, China Medical University Hospital, China Medical UniversityTaichung 40402, Taiwan
| | - King-The Lee
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical UniversityKaohsiung 80708, Taiwan
- Hepatobiliary-Pancreatic Surgery, Park One International HospitalKaohsiung 81357, Taiwan
| | - Chong-Chi Chiu
- Department of General Surgery, E-Da Cancer HospitalKaohsiung 82445, Taiwan
- School of Medicine, College of Medicine, I-Shou UniversityKaohsiung 82445, Taiwan
| | - Jhi-Joung Wang
- Department of Medical Research, Chi Mei Medical CenterYongkang, Tainan 71004, Taiwan
- Allied AI Biomed Center, Southern Taiwan University of Science and TechnologyTainan 71005, Taiwan
| | - Ding-Ping Sun
- Department of Surgery, Chi Mei Medical CenterYongkang, Tainan 71004, Taiwan
| | - Hao-Hsien Lee
- Department of Surgery, Chi Mei Medical CenterLiouying, Tainan 73658, Taiwan
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Buondonno A, Avella P, Cappuccio M, Scacchi A, Vaschetti R, Di Marzo G, Maida P, Luciani C, Amato B, Brunese MC, Esposito D, Selvaggi L, Guerra G, Rocca A. A Hub and Spoke Learning Program in Bariatric Surgery in a Small Region of Italy. Front Surg 2022; 9:855527. [PMID: 35402486 PMCID: PMC8987280 DOI: 10.3389/fsurg.2022.855527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 01/25/2022] [Indexed: 01/25/2023] Open
Abstract
BackgroundMetabolic and bariatric surgery (BS) are considered life-changing and life-saving treatments for obese patients. The Italian Society of Obesity Surgery (SICOB) requires at least 25 operations per year to achieve the standard of care in the field. Despite the increasing need to treat obese patients, some small southern regions of Italy, such as Molise, do not have enough experience in bariatric procedures to be allowed to perform them. Therefore, our aim was to run a Hub and Spoke Program with a referral center in BS to treat obese patients and provide a proper learning curve in BS in Molise.MethodsIn 2020, the “A. Cardarelli Hospital” in Campobasso, Molise, started a formal “Learning Model of Hub and Spoke Collaboration” with the Hub center “Ospedale Del Mare”, Naples. A multidisciplinary approach was achieved. Patients were supervised and operated under the supervision and tutoring of the referral center. We retrospectively reviewed our prospectively collected database from February 2020 to August 2021 in order to analyze the safety and effectiveness of our learning program.ResultsIn total, 13 (3 men and 10 women) patients underwent BS with the mean age of 47.08 years and a presurgery BMI of 41.79. Seven (53.84%) patients were the American Society of Anesthesiologist (ASA) II, and 6 (46.16%) patients were ASA III. Twelve (92.31%) procedures were laparoscopic sleeve gastrectomies, 1 (7.69%) patient underwent endoscopic BioEnterics Intragastric Balloon (BIB) placement. One (8.33%) sleeve gastrectomy was associated to gastric band removal. Mean surgical time was 110.14 ± 23.54 min. The mean length of stay was 4.07 ± 2.40 days. No Clavien-Dindo ≥ III and mortality were reported. The follow-up program showed a mean decrease of 11.82 in terms of body mass index (BMI) value. The last 5 procedures were performed by the whole equips from “A. Cardarelli” under external tutoring without any impact on complication rate.ConclusionThe setup of a proper Hub and Spoke Program may allow to perform BS to provide the standard of care. This approach may reduce health costs and related patient migration.
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Affiliation(s)
| | - Pasquale Avella
- Department of Medicine and Health Science, University of Molise, Campobasso, Italy
| | - Micaela Cappuccio
- Department of Medicine and Health Science, University of Molise, Campobasso, Italy
| | - Andrea Scacchi
- Department of Medicine and Health Science, University of Molise, Campobasso, Italy
- *Correspondence: Andrea Scacchi
| | - Roberto Vaschetti
- Department of Medicine and Health Science, University of Molise, Campobasso, Italy
- Roberto Vaschetti
| | | | - Pietro Maida
- General Surgery Unit, Ospedale del Mare, Centro Sanitario Locale Napoli 1 Centro, Naples, Italy
| | - Claudio Luciani
- General Surgery Unit, A. Cardarelli Hospital, Campobasso, Italy
| | - Bruno Amato
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Maria Chiara Brunese
- Department of Medicine and Health Science, University of Molise, Campobasso, Italy
| | - Daniela Esposito
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg and Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lucio Selvaggi
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania “Luigi Vanvitelli”, Naples, Italy
| | - Germano Guerra
- Department of Medicine and Health Science, University of Molise, Campobasso, Italy
| | - Aldo Rocca
- General Surgery Unit, A. Cardarelli Hospital, Campobasso, Italy
- Department of Medicine and Health Science, University of Molise, Campobasso, Italy
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