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Rompianesi G, Montalti R, Vrakas G, Zarrinpar A, Warren C, Loiaco G, Rubba F, Troisi RI. Benchmark Outcomes in Deceased Donor Kidney Transplantation: A Multicenter Analysis of 80 996 Transplants From 126 Centers. Transplant Direct 2024; 10:e1618. [PMID: 38606349 PMCID: PMC11005896 DOI: 10.1097/txd.0000000000001618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/05/2024] [Accepted: 02/08/2024] [Indexed: 04/13/2024] Open
Abstract
Background We defined clinically relevant benchmark values in deceased donor kidney transplantation (KT), to assess the best achievable results in low-risk patient cohorts from experienced centers. Methods We identified the "ideal" cases from the United Network for Organ Sharing Standard Transplant Analysis and Research files from centers performing ≥50 KT per year between 2010 and 2018. Cases have been selected based on the kidney donor profile index values (<35%), a cold ischemia time (CIT) ≤18 h, a HLA mismatch ≤4, and excluding blood group (ABO) incompatible, dual and combined transplants. The outcomes of the benchmark cohort have been compared with a group of patients excluded from the benchmark cohort because but not meeting 1 or more of the abovementioned criteria. Results The 171 424 KT patients in the United Network for Organ Sharing Standard Transplant Analysis and Research files were screened and 8694 benchmark cases of a total of 80 996 KT (10.7%) from 126 centers meeting the selection criteria were identified. The benchmarks for 1-, 3-, and 5-y patient survival are ≥97%, ≥92.5%, and ≥86.7%, and ≥95.4%, ≥87.8%, and ≥79.6% for graft survival. Benchmark cutoff for hospital length of stay is ≤5 d, ≤23.6% for delayed graft function, and ≤7.5% and ≤9.1% for 6-mo and 1-y incidence of acute rejection. Overall 1-, 3-, and 5-y actuarial graft survivals were 96.6%, 91.1%, and 84.2% versus 93.5%, 85.4%, and 75.5% in the benchmark and comparison groups, respectively (P < 0.001). Overall 1-, 3-, and 5-y actuarial patient survivals were 98.1%, 94.8%, and 90.0% versus 96.6%, 91.1%, and 83.0% in the benchmark and comparison groups, respectively (P < 0.001). Conclusions For the first time, we quantified the best achievable postoperative results in an ideal scenario in deceased donor KT, aimed at improving the clinical practice guided by the comparison of center performances with the ideal outcomes defined.
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Affiliation(s)
- Gianluca Rompianesi
- Division of Hepato-Biliary-Pancreatic, Minimally Invasive, Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University Hospital of Naples, Italy
| | - Roberto Montalti
- Division of Hepato-Biliary-Pancreatic, Minimally Invasive, Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University Hospital of Naples, Italy
| | - Georgios Vrakas
- Department of Surgery, University of Florida, Gainesville, FL
| | - Ali Zarrinpar
- Department of Surgery, University of Florida, Gainesville, FL
| | - Curtis Warren
- Department of Surgery, University of Florida, Gainesville, FL
| | - Giuseppe Loiaco
- Division of Hepato-Biliary-Pancreatic, Minimally Invasive, Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University Hospital of Naples, Italy
| | - Fabiana Rubba
- Public Health Department, Federico II University Hospital, Naples, Italy
| | - Roberto I. Troisi
- Division of Hepato-Biliary-Pancreatic, Minimally Invasive, Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University Hospital of Naples, Italy
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Milone M, Anoldo P, Manigrasso M, Cantore G, Campanile S, Rompianesi G, Troisi RI, D'Amore A, De Palma GD. Robotic 8-mm trocar fascial wounds: To close or not to close? Int J Med Robot 2024; 20:e2624. [PMID: 38430543 DOI: 10.1002/rcs.2624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 02/13/2024] [Accepted: 02/22/2024] [Indexed: 03/04/2024]
Abstract
BACKGROUND The aim of this study was to investigate 8-mm robotic trocar site hernia (TSH) rate over the short and long term, providing aids to manage the related fascial wounds. METHODS A retrospective analysis of 320 patients undergoing robotic surgery was conducted. The primary outcome was 8-mm TSH rate with a minimum follow-up of 12 months. The secondary outcome was the rate of haematomas and infections related to 8-mm wounds and their association with patient comorbidities and trocar position. RESULTS One case of TSH was observed (0.31%). There were 15 cases of wound infection (4.68%) and 22 cases of wound haematoma (6.87%). Trocar related complications were significantly associated with patient comorbidities, not with trocar position. CONCLUSIONS Our results do not justify the 8-mm fascial wound closure. Data concerning the association between trocar-related complications and patient comorbidities strengthen the need to implement the control of metabolic state and correct administration of perioperative therapy in high-risk patients.
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Affiliation(s)
- Marco Milone
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - Pietro Anoldo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Michele Manigrasso
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - Grazia Cantore
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - Silvia Campanile
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - Gianluca Rompianesi
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - Roberto Ivan Troisi
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
| | - Anna D'Amore
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy
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Rompianesi G, Tamburrino D. Editorial: The predictive benefits of inflammatory markers in cancers of the liver. Front Oncol 2024; 14:1386388. [PMID: 38559564 PMCID: PMC10978587 DOI: 10.3389/fonc.2024.1386388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 03/05/2024] [Indexed: 04/04/2024] Open
Affiliation(s)
- Gianluca Rompianesi
- Hepato-Bilio-Pancreatic, Minimally-invasive, Robotic and Transplant Surgery Unit, Federico II University Hospital, Naples, Italy
| | - Domenico Tamburrino
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
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Montalti R, Cassese G, Zidan A, Rompianesi G, Cesare Giglio M, Campanile S, Arena L, Maione M, Troisi RI. Local recurrence risk factors and outcomes in minimally invasive thermal ablation for liver tumors: a single-institution analysis. HPB (Oxford) 2024:S1365-182X(24)00015-7. [PMID: 38342647 DOI: 10.1016/j.hpb.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/27/2023] [Accepted: 01/26/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND Minimally Invasive thermal ablation (MITA) of liver tumors is a commonly performed procedure, alone or in combination with liver resection. Despite being a first-option strategy for small lesions, it is technically demanding, and many concerns still exist about local disease control. METHODS Consecutive patients undergoing MITA from 1-2019 to 12-2022 were retrospectively enrolled. Risk factors of local recurrence were investigated through univariate and multivariable cox regression analysis. RESULTS At the multivariable analysis of the 207 nodules undergoing MITA, RFA was associated with worse local Recurrence Free Survival (lRFS) than MWA (HR 2.87 [95 % CI 0.96-8.66], p = 0.05), as well as a concomitant surgical resection (HR 3.89 [95 % CI 1.06-9.77], p = 0.02). A concomitant surgical resection showed worse lRFS in the subgroup analysis of both HCC (HR 3.98 [95 % CI 1.16-13.62], p = 0.02) and CRLM patients (HR 2.68 [95 % CI 0.66-5.92], p = 0.04). Interestingly, a tumor size between 30 and 40 mm was not associated to worse lRFS. CONCLUSION MWA may reduce the risk of local recurrence in comparison to RFA, while MITA associated to liver resection may face an increased risk of local recurrence. Further prospective studies are needed to confirm such results.
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Affiliation(s)
- Roberto Montalti
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic HPB Surgery, Federico II University Hospital, Naples, Italy; Department of Public Health, Federico II University, Naples, Italy
| | - Gianluca Cassese
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic HPB Surgery, Federico II University Hospital, Naples, Italy.
| | - Ahmed Zidan
- Department of Surgery, Assiut University Hospital, Assiut, Egypt
| | - Gianluca Rompianesi
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic HPB Surgery, Federico II University Hospital, Naples, Italy
| | - Mariano Cesare Giglio
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic HPB Surgery, Federico II University Hospital, Naples, Italy
| | - Silvia Campanile
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic HPB Surgery, Federico II University Hospital, Naples, Italy
| | - Lorenza Arena
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic HPB Surgery, Federico II University Hospital, Naples, Italy
| | - Marco Maione
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic HPB Surgery, Federico II University Hospital, Naples, Italy
| | - Roberto I Troisi
- Department of Clinical Medicine and Surgery, Division of Minimally Invasive and Robotic HPB Surgery, Federico II University Hospital, Naples, Italy
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Berardi G, Ivanics T, Sapisochin G, Ratti F, Sposito C, Nebbia M, D'Souza DM, Pascual F, Tohme S, D'Amico FE, Alessandris R, Panetta V, Simonelli I, Del Basso C, Russolillo N, Fiorentini G, Serenari M, Rotellar F, Zimitti G, Famularo S, Hoffman D, Onkendi E, Lopez-Ben S, Caula C, Rompianesi G, Chopra A, Abu Hilal M, Torzilli G, Corvera C, Alseidi A, Helton S, Troisi RI, Simo K, Conrad C, Cescon M, Cleary S, Kwon CHD, Ferrero A, Ettorre GM, Cillo U, Geller D, Cherqui D, Serrano PE, Ferrone C, Mazzaferro V, Aldrighetti L, Kingham TP. Minimally Invasive Versus Open Liver Resections for Hepatocellular Carcinoma in Patients With Metabolic Syndrome. Ann Surg 2023; 278:e1041-e1047. [PMID: 36994755 DOI: 10.1097/sla.0000000000005861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
OBJECTIVE To compare minimally invasive (MILR) and open liver resections (OLRs) for hepatocellular carcinoma (HCC) in patients with metabolic syndrome (MS). BACKGROUND Liver resections for HCC on MS are associated with high perioperative morbidity and mortality. No data on the minimally invasive approach in this setting exist. MATERIAL AND METHODS A multicenter study involving 24 institutions was conducted. Propensity scores were calculated, and inverse probability weighting was used to weight comparisons. Short-term and long-term outcomes were investigated. RESULTS A total of 996 patients were included: 580 in OLR and 416 in MILR. After weighing, groups were well matched. Blood loss was similar between groups (OLR 275.9±3.1 vs MILR 226±4.0, P =0.146). There were no significant differences in 90-day morbidity (38.9% vs 31.9% OLRs and MILRs, P =0.08) and mortality (2.4% vs 2.2% OLRs and MILRs, P =0.84). MILRs were associated with lower rates of major complications (9.3% vs 15.3%, P =0.015), posthepatectomy liver failure (0.6% vs 4.3%, P =0.008), and bile leaks (2.2% vs 6.4%, P =0.003); ascites was significantly lower at postoperative day 1 (2.7% vs 8.1%, P =0.002) and day 3 (3.1% vs 11.4%, P <0.001); hospital stay was significantly shorter (5.8±1.9 vs 7.5±1.7, P <0.001). There was no significant difference in overall survival and disease-free survival. CONCLUSIONS MILR for HCC on MS is associated with equivalent perioperative and oncological outcomes to OLRs. Fewer major complications, posthepatectomy liver failures, ascites, and bile leaks can be obtained, with a shorter hospital stay. The combination of lower short-term severe morbidity and equivalent oncologic outcomes favor MILR for MS when feasible.
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Affiliation(s)
- Giammauro Berardi
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Surgery, San Camillo Forlanini Hospital, Rome, Italy
| | - Tommy Ivanics
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | | | - Francesca Ratti
- Division, San Raffaele Hospital, Hepatobiliary Surgery Milan, Italy
| | - Carlo Sposito
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Department of Surgery, HPB Surgery and Liver Transplantation, Istituto Nazionale Tumori IRCCS, Milan, Italy
| | - Martina Nebbia
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Daniel M D'Souza
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Franco Pascual
- Department of Surgery, Paul Brousse Hospital, Villejuif, Paris, France
| | - Samer Tohme
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | | | - Valentina Panetta
- L'altrastatistica Consultancy and Training, Biostatistics Department, Rome, Italy
| | - Ilaria Simonelli
- L'altrastatistica Consultancy and Training, Biostatistics Department, Rome, Italy
| | | | | | | | - Matteo Serenari
- Hepatobiliary surgery and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Fernando Rotellar
- Hepatobiliary and Liver Transplantation Unit, Department of Surgery, University Clinic, Universidad de Navarra, Pamplona, Spain; Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | - Giuseppe Zimitti
- Department of surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Simone Famularo
- Department of General Surgery, Humanitas University and Research Hospital, IRCCS, Milan, Italy
| | - Daniel Hoffman
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Edwin Onkendi
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Santiago Lopez-Ben
- Department of Surgery, Hospital Universitari Dr Josep Trueta de Girona, Girona, Spain
| | - Celia Caula
- Department of Surgery, Hospital Universitari Dr Josep Trueta de Girona, Girona, Spain
| | - Gianluca Rompianesi
- Division of HPB, Minimally Invasive and Robotic Surgery, Transplantation Service, Federico II University Naples
| | | | - Mohammed Abu Hilal
- Department of surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Guido Torzilli
- Department of General Surgery, Humanitas University and Research Hospital, IRCCS, Milan, Italy
| | - Carlos Corvera
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Adnan Alseidi
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - Scott Helton
- Department of Surgery, Virginia Mason Hospital and Seattle Medical Center, Seattle, WA
| | - Roberto I Troisi
- Division of HPB, Minimally Invasive and Robotic Surgery, Transplantation Service, Federico II University Naples
| | - Kerri Simo
- Department of Surgery, Promedica Toledo, Toledo, OH
| | - Claudius Conrad
- Department of Surgery, Saint Elizabeth Medical Center, Boston, MA
| | - Matteo Cescon
- Hepatobiliary surgery and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Sean Cleary
- Department of Surgery, Mayo Clinic, Rochester, NY
| | | | | | | | - Umberto Cillo
- Department of Surgery, University of Padua, Padua, Italy
| | - David Geller
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Daniel Cherqui
- Department of Surgery, Paul Brousse Hospital, Villejuif, Paris, France
| | - Pablo E Serrano
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Cristina Ferrone
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Vincenzo Mazzaferro
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Department of Surgery, HPB Surgery and Liver Transplantation, Istituto Nazionale Tumori IRCCS, Milan, Italy
| | - Luca Aldrighetti
- Division, San Raffaele Hospital, Hepatobiliary Surgery Milan, Italy
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Rompianesi G, Pegoraro F, Ramaci L, Ceresa CD, Montalti R, Troisi RI. Preoperative planning and intraoperative real-time navigation with indocyanine green fluorescence in robotic liver surgery. Langenbecks Arch Surg 2023; 408:292. [PMID: 37522938 PMCID: PMC10390613 DOI: 10.1007/s00423-023-03024-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/20/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE We aimed at exploring indocyanine green (ICG) fluorescence wide spectrum of applications in hepatobiliary surgery as can result particularly useful in robotic liver resections (RLR) in order to overcome some technical limitations, increasing safety, and efficacy. METHODS We describe our experience of 76 RLR performed between March 2020 and December 2022 exploring all the possible applications of pre- and intraoperative ICG administration. RESULTS Hepatocellular carcinoma and colorectal liver metastases were the most common indications for RLR (34.2% and 26.7% of patients, respectively), and 51.3% of cases were complex resections with high IWATE difficulty scores. ICG was administered preoperatively in 61 patients (80.3%), intraoperatively in 42 patients (55.3%) and in both contexts in 25 patients (32.9%), with no observed adverse events. The most frequent ICG goal was to achieve tumor enhancement (59 patients, 77.6%), with a success rate of 94.9% and the detection of 3 additional malignant lesions. ICG facilitated evaluation of the resection margin for residual tumor and perfusion adequacy in 33.9% and 32.9% of cases, respectively, mandating a resection enlargement in 7.9% of patients. ICG fluorescence allowed the identification of the transection plane through negative staining in the 25% of cases. Vascular and biliary structures were visualized in 21.1% and 9.2% of patients, with a success rate of 81.3% and 85.7%, respectively. CONCLUSION RLR can benefit from the routine integration of ICG fluoresce evaluation according to each individual patient and condition-specific goals and issues, allowing liver functional assessment, anatomical and vascular evaluation, tumor detection, and resection margins assessment.
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Affiliation(s)
- Gianluca Rompianesi
- Division of Hepato-Biliary-Pancreatic, Minimally Invasive and Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University Hospital, via S. Pansini n. 5, Naples, Italy.
| | - Francesca Pegoraro
- Division of Hepato-Biliary-Pancreatic, Minimally Invasive and Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University Hospital, via S. Pansini n. 5, Naples, Italy
| | - Lorenzo Ramaci
- Division of Hepato-Biliary-Pancreatic, Minimally Invasive and Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University Hospital, via S. Pansini n. 5, Naples, Italy
| | - Carlo Dl Ceresa
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Roberto Montalti
- Division of Hepato-Biliary-Pancreatic, Minimally Invasive and Robotic Surgery and Kidney Transplantation, Department of Public Health Federico II University Hospital, Naples, Italy
| | - Roberto I Troisi
- Division of Hepato-Biliary-Pancreatic, Minimally Invasive and Robotic Surgery and Kidney Transplantation, Department of Clinical Medicine and Surgery, Federico II University Hospital, via S. Pansini n. 5, Naples, Italy
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Berardi G, Ratti F, Sposito C, Nebbia M, D’Souza DM, Pascual F, Dogeas E, Tohme S, D’Amico FE, Alessandris R, Simonelli I, Del Basso C, Russolillo N, Moro A, Fiorentini G, Serenari M, Rotellar F, Zimmitti G, Famularo S, Ivanics T, Hoffman D, Onkendi E, Essaji Y, Lopez Ben S, Caula C, Rompianesi G, Chopra A, Abu Hilal M, Torzilli G, Sapisochin G, Corvera C, Alseidi A, Helton S, Troisi RI, Simo K, Conrad C, Cescon M, Cleary S, Kwon CH, Ferrero A, Ettorre GM, Cillo U, Geller D, Cherqui D, Serrano PE, Ferrone C, Mazzaferro V, Aldrighetti L, Kingham TP. Model to predict major complications following liver resection for HCC in patients with metabolic syndrome. Hepatology 2023; 77:1527-1539. [PMID: 36646670 PMCID: PMC10121838 DOI: 10.1097/hep.0000000000000027] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 10/01/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Metabolic syndrome (MS) is rapidly growing as risk factor for HCC. Liver resection for HCC in patients with MS is associated with increased postoperative risks. There are no data on factors associated with postoperative complications. AIMS The aim was to identify risk factors and develop and validate a model for postoperative major morbidity after liver resection for HCC in patients with MS, using a large multicentric Western cohort. MATERIALS AND METHODS The univariable logistic regression analysis was applied to select predictive factors for 90 days major morbidity. The model was built on the multivariable regression and presented as a nomogram. Performance was evaluated by internal validation through the bootstrap method. The predictive discrimination was assessed through the concordance index. RESULTS A total of 1087 patients were gathered from 24 centers between 2001 and 2021. Four hundred and eighty-four patients (45.2%) were obese. Most liver resections were performed using an open approach (59.1%), and 743 (68.3%) underwent minor hepatectomies. Three hundred and seventy-six patients (34.6%) developed postoperative complications, with 13.8% major morbidity and 2.9% mortality rates. Seven hundred and thirteen patients had complete data and were included in the prediction model. The model identified obesity, diabetes, ischemic heart disease, portal hypertension, open approach, major hepatectomy, and changes in the nontumoral parenchyma as risk factors for major morbidity. The model demonstrated an AUC of 72.8% (95% CI: 67.2%-78.2%) ( https://childb.shinyapps.io/NomogramMajorMorbidity90days/ ). CONCLUSIONS Patients undergoing liver resection for HCC and MS are at high risk of postoperative major complications and death. Careful patient selection, considering baseline characteristics, liver function, and type of surgery, is key to achieving optimal outcomes.
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Affiliation(s)
- Giammauro Berardi
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Surgery, San Camillo Forlanini Hospital, Rome, Italy
| | - Francesca Ratti
- Hepatobiliary Surgery Division, San Raffaele Hospital, Milan, Italy
| | - Carlo Sposito
- Department of Oncology and Hemato-Oncology, University of Milan and Department of Surgery, HPB Surgery and Liver Transplantation, Istituto Nazionale Tumori IRCCS, Milan, Italy
| | - Martina Nebbia
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Franco Pascual
- Department of Surgery, Paul Brousse Hospital, Villejuif, Paris, France
| | - Epameinondas Dogeas
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Samer Tohme
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | | | - Ilaria Simonelli
- Laltrastatistica Consultancy and Training, Biostatistics Department, Rome, Italy
| | | | | | - Amika Moro
- Department of Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Guido Fiorentini
- Hepatobiliary Surgery Division, San Raffaele Hospital, Milan, Italy
- Department of Surgery, Mayo Clinic, Rochester, New York State, USA
| | - Matteo Serenari
- Hepato-biliary Surgery and Transplant Unit, IRCCS Sant’Orsola Hospital, University of Bologna, Bologna, Italy and Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Fernando Rotellar
- HPB and Liver Transplant Unit, Clinica Universidad de Navarra, University of Navarra. Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | - Giuseppe Zimmitti
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Simone Famularo
- Hepatobiliary Surgery Division, Humanitas University and Research Hospital- IRCCS, Rozzano - Milano. Italy
| | - Tommy Ivanics
- Abdominal Transplant and HPB Surgical Oncology, Division of General Surgery, Toronto General Hospital
| | - Daniel Hoffman
- Department of Surgery, University of California, San Francisco, California, USA
| | - Edwin Onkendi
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Yasmin Essaji
- Department of Surgery, Virginia Mason Hospital and Seattle Medical Center, Seattle, Washington, USA
| | - Santiago Lopez Ben
- Department of Surgery, Hospital Universitari Dr Josep Trueta de Girona, Girona, Spain
| | - Celia Caula
- Department of Surgery, Hospital Universitari Dr Josep Trueta de Girona, Girona, Spain
| | - Gianluca Rompianesi
- Department of clinical medicine and surgery, division of HPB, minimally invasive and robotic surgery, transplantation service, Università Federico II, Naples, Italy
| | | | - Mohammed Abu Hilal
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Guido Torzilli
- Hepatobiliary Surgery Division, Humanitas University and Research Hospital- IRCCS, Rozzano - Milano. Italy
| | - Gonzalo Sapisochin
- Abdominal Transplant and HPB Surgical Oncology, Division of General Surgery, Toronto General Hospital
| | - Carlos Corvera
- Department of Surgery, University of California, San Francisco, California, USA
| | - Adnan Alseidi
- Department of Surgery, University of California, San Francisco, California, USA
| | - Scott Helton
- Department of Surgery, Virginia Mason Hospital and Seattle Medical Center, Seattle, Washington, USA
| | - Roberto I. Troisi
- Department of clinical medicine and surgery, division of HPB, minimally invasive and robotic surgery, transplantation service, Università Federico II, Naples, Italy
| | - Kerri Simo
- Department of Surgery, Promedica, Toledo, Ohio, USA
| | - Claudius Conrad
- Department of Surgery, Saint Elizabeth Medical Center, Boston, Massachusetts, USA
| | - Matteo Cescon
- Hepato-biliary Surgery and Transplant Unit, IRCCS Sant’Orsola Hospital, University of Bologna, Bologna, Italy and Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Sean Cleary
- Department of Surgery, Mayo Clinic, Rochester, New York State, USA
| | - Choon H.D. Kwon
- Department of Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - Umberto Cillo
- Department of Surgery, University of Padua, Padua, Italy
| | - David Geller
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Daniel Cherqui
- Department of Surgery, Paul Brousse Hospital, Villejuif, Paris, France
| | | | - Cristina Ferrone
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Vincenzo Mazzaferro
- Department of Oncology and Hemato-Oncology, University of Milan and Department of Surgery, HPB Surgery and Liver Transplantation, Istituto Nazionale Tumori IRCCS, Milan, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, San Raffaele Hospital, Milan, Italy
| | - T. Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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8
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Montalti R, Rompianesi G, Cassese G, Pegoraro F, Giglio MC, De Simone G, Rashidian N, Venetucci P, Troisi RI. Role of preoperative 3D rendering for minimally invasive parenchyma sparing liver resections. HPB (Oxford) 2023:S1365-182X(23)00125-9. [PMID: 37149483 DOI: 10.1016/j.hpb.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 03/23/2023] [Accepted: 04/13/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND 3D rendering (3DR) represents a promising approach to plan surgical strategies. The study aimed to compare the results of minimally invasive liver resections (MILS) in patients with 3DR versus conventional 2D CT-scan. METHODS We performed 118 3DR for various indications; the patients underwent a preoperative tri-phasic CT-scan and rendered with Synapse3D® Software. Fifty-six patients undergoing MILS with pre-operative 3DR were compared to a similar cohort of 127 patients undergoing conventional pre-operative 2D CT-scan using the propensity score matching (PSM) analysis. RESULTS The 3DR mandated pre-operative surgical plan variations in 33.9% cases, contraindicated surgery in 12.7%, providing a new surgical indication in 5.9% previously excluded cases. PSM identified 39 patients in both groups with comparable results in terms of conversion rates, blood loss, blood transfusions, parenchymal R1-margins, grade ≥3 Clavien-Dindo complications, 90-days mortality, and hospital stay respectively in 3DR and conventional 2D. Operative time was significantly increased in the 3DR group (402 vs. 347 min, p = 0.020). Vascular R1 resections were 25.6% vs 7.7% (p = 0.068), while the conversion rate was 0% vs 10.2% (p = 0.058), respectively, for 3DR group vs conventional 2D. CONCLUSION 3DR may help in surgical planning increasing resectability rate while reducing conversion rates, allowing the precise identification of anatomical landmarks in minimally invasive parenchyma-preserving liver resections.
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Affiliation(s)
- Roberto Montalti
- Department of Public Health, Federico II University, Naples, Italy; Department of Clinical Medicine and Surgery, Division of HPB, Minimally Invasive and Robotic Surgery, Renal Transplant Service, Federico II University, Naples, Italy
| | - Gianluca Rompianesi
- Department of Clinical Medicine and Surgery, Division of HPB, Minimally Invasive and Robotic Surgery, Renal Transplant Service, Federico II University, Naples, Italy
| | - Gianluca Cassese
- Department of Clinical Medicine and Surgery, Division of HPB, Minimally Invasive and Robotic Surgery, Renal Transplant Service, Federico II University, Naples, Italy
| | - Francesca Pegoraro
- Department of Clinical Medicine and Surgery, Division of HPB, Minimally Invasive and Robotic Surgery, Renal Transplant Service, Federico II University, Naples, Italy
| | - Mariano C Giglio
- Department of Clinical Medicine and Surgery, Division of HPB, Minimally Invasive and Robotic Surgery, Renal Transplant Service, Federico II University, Naples, Italy
| | - Giuseppe De Simone
- Department of Anesthesiology and Intensive Care, Federico II University, Naples, Italy
| | - Nikdokht Rashidian
- Department of Hepatobiliary and Liver Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Pietro Venetucci
- Division of Medical Imaging and Radiotherapy, Department of Onco-Hematology, Diagnostic and Morphologic Imaging, and Forensic Medicine, Federico II University, Naples, Italy
| | - Roberto I Troisi
- Department of Clinical Medicine and Surgery, Division of HPB, Minimally Invasive and Robotic Surgery, Renal Transplant Service, Federico II University, Naples, Italy.
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9
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Rompianesi G. Editorial: Radiofrequency ablation in liver cancers: Investigations of efficacy as monotherapy and polytherapy. Front Oncol 2022; 12:1088012. [PMID: 36582784 PMCID: PMC9793076 DOI: 10.3389/fonc.2022.1088012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/23/2022] [Indexed: 12/15/2022] Open
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10
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Troisi R, Rompianesi G, Giglio M, Montalti R. The democratizing effects of robotic surgery: Nine HPB manoeuvres exactly reproduced by the da vinci system. Surg Oncol 2022; 44:101822. [DOI: 10.1016/j.suronc.2022.101822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 07/05/2022] [Accepted: 07/24/2022] [Indexed: 11/29/2022]
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11
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Shankar S, Beckett J, Tipton T, Ogbe A, Kasanyinga M, Dold C, Lumley S, Dengu F, Rompianesi G, Elgilani F, Longet S, Deeks A, Payne RP, Duncan CJ, Richter A, de Silva TI, Turtle L, Bull K, Barnardo M, Friend PJ, Dunachie SJ, Hester J, Issa F, Barnes E, Carroll MW, Klenerman P. SARS-CoV-2-Specific T Cell Responses Are Not Associated with Protection against Reinfection in Hemodialysis Patients. J Am Soc Nephrol 2022; 33:883-887. [PMID: 35361708 PMCID: PMC9063898 DOI: 10.1681/asn.2021121587] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Significance Statement
Patients on hemodialysis (HD) are vulnerable to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and mount poor neutralizing antibody responses after two-dose vaccination. Although serological responses have been associated with reduced rates of reinfection, the relationship between cellular immunogenicity and protection has not been established. We report, for the first time, high incidence of reinfection in patients on HD who are vaccine naive (25%), which identifies that T cell responses do not predict protection against reinfection. Instead, patients on HD who went on to become reinfected had mounted highly variable and sometimes robust proliferative T cell responses to a broad array of SARS-CoV-2 peptide pools during the primary infection. The understanding that SARS-CoV-2–specific T cell responses are not predictive of protection against future infection will be a critical issue when measuring clinical efficacy of vaccination in these vulnerable cohorts, particularly when facing rapidly emerging variants of concern.
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Affiliation(s)
- Sushma Shankar
- Transplantation Research and Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
- Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
- Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Joseph Beckett
- Transplantation Research and Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Tom Tipton
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | - Ane Ogbe
- Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, United Kingdom
| | - Mwila Kasanyinga
- Oxford Vaccine Group, University of Oxford, Oxford, United Kingdom
| | - Christina Dold
- Oxford Vaccine Group, University of Oxford, Oxford, United Kingdom
| | - Sheila Lumley
- Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Fungai Dengu
- Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
- Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Gianluca Rompianesi
- Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
- Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Faysal Elgilani
- Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
- Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Stephanie Longet
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | - Alexandra Deeks
- Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, United Kingdom
| | - Rebecca P. Payne
- Translational and Clinical Research Institute Immunity and Inflammation Theme, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Christopher J.A. Duncan
- Translational and Clinical Research Institute Immunity and Inflammation Theme, Newcastle University, Newcastle upon Tyne, United Kingdom
- Department of Infection and Tropical Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Alex Richter
- Institute of Cancer and Genomic Science, College of Medical and Dental Science, University of Birmingham, Birmingham, United Kingdom
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Thushan I. de Silva
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Lance Turtle
- National Institute for Health Research Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
- Liverpool University Hospitals NHS Trust, Liverpool, United Kingdom
| | - Katherine Bull
- Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Martin Barnardo
- Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
- Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Peter J. Friend
- Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
- Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Susanna J. Dunachie
- Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
- Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, United Kingdom
- Oxford Centre for Global Health Research, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Joanna Hester
- Transplantation Research and Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Fadi Issa
- Transplantation Research and Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Eleanor Barnes
- Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
- Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, United Kingdom
| | - Miles W. Carroll
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | - Paul Klenerman
- Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
- Peter Medawar Building for Pathogen Research, University of Oxford, Oxford, United Kingdom
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Milone M, Manigrasso M, Anoldo P, D’Amore A, Elmore U, Giglio MC, Rompianesi G, Vertaldi S, Troisi RI, Francis NK, De Palma GD. The Role of Robotic Visceral Surgery in Patients with Adhesions: A Systematic Review and Meta-Analysis. J Pers Med 2022; 12:jpm12020307. [PMID: 35207795 PMCID: PMC8878352 DOI: 10.3390/jpm12020307] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/08/2022] [Accepted: 02/14/2022] [Indexed: 12/17/2022] Open
Abstract
Abdominal adhesions are a risk factor for conversion to open surgery. An advantage of robotic surgery is the lower rate of unplanned conversions. A systematic review was conducted using the terms “laparoscopic” and “robotic”. Inclusion criteria were: comparative studies evaluating patients undergoing laparoscopic and robotic surgery; reporting data on conversion to open surgery for each group due to adhesions and studies including at least five patients in each group. The main outcomes were the conversion rates due to adhesions and surgeons’ expertise (novice vs. expert). The meta-analysis included 70 studies from different surgical specialities with 14,329 procedures (6472 robotic and 7857 laparoscopic). The robotic approach was associated with a reduced risk of conversion (OR 1.53, 95% CI 1.12–2.10, p = 0.007). The analysis of the procedures performed by “expert surgeons” showed a statistically significant difference in favour of robotic surgery (OR 1.48, 95% CI 1.03–2.12, p = 0.03). A reduced conversion rate due to adhesions with the robotic approach was observed in patients undergoing colorectal cancer surgery (OR 2.62, 95% CI 1.20–5.72, p = 0.02). The robotic approach could be a valid option in patients with abdominal adhesions, especially in the subgroup of those undergoing colorectal cancer resection performed by expert surgeons.
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Affiliation(s)
- Marco Milone
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.D.); (M.C.G.); (G.R.); (S.V.); (R.I.T.); (G.D.D.P.)
- Correspondence: ; Tel.: +39-333-299-3637
| | - Michele Manigrasso
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (M.M.); (P.A.)
| | - Pietro Anoldo
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (M.M.); (P.A.)
| | - Anna D’Amore
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.D.); (M.C.G.); (G.R.); (S.V.); (R.I.T.); (G.D.D.P.)
| | - Ugo Elmore
- Department of Surgery, San Raffaele Hospital and San Raffaele Vita-Salute University, 20132 Milan, Italy;
| | - Mariano Cesare Giglio
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.D.); (M.C.G.); (G.R.); (S.V.); (R.I.T.); (G.D.D.P.)
| | - Gianluca Rompianesi
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.D.); (M.C.G.); (G.R.); (S.V.); (R.I.T.); (G.D.D.P.)
| | - Sara Vertaldi
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.D.); (M.C.G.); (G.R.); (S.V.); (R.I.T.); (G.D.D.P.)
| | - Roberto Ivan Troisi
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.D.); (M.C.G.); (G.R.); (S.V.); (R.I.T.); (G.D.D.P.)
| | | | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.D.); (M.C.G.); (G.R.); (S.V.); (R.I.T.); (G.D.D.P.)
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13
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Rompianesi G, Montalti R, Giglio MC, Caruso E, Ceresa CD, Troisi RI. Robotic central pancreatectomy: a systematic review and meta-analysis. HPB (Oxford) 2022; 24:143-151. [PMID: 34625342 DOI: 10.1016/j.hpb.2021.09.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 07/27/2021] [Accepted: 09/15/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Central pancreatectomy is usually performed to excise lesions of the neck or proximal body of the pancreas. In the last decade, thanks to the advent of novel technologies, surgeons have started to perform this procedure robotically. This review aims to appraise the results and outcomes of robotic central pancreatectomies (RCP) through a systematic review and meta-analysis. METHODS A systematic search of MEDLINE, Embase, and Web Of Science identified studies reporting outcomes of RCP. Pooled prevalence rates of postoperative complications and mortality were computed using random-effect modelling. RESULTS Thirteen series involving 265 patients were included. In all cases but one, RCP was performed to excise benign or low-grade tumours. Clinically relevant post-operative pancreatic fistula (POPF) occurred in 42.3% of patients. While overall complications were reported in 57.5% of patients, only 9.4% had a Clavien-Dindo score ≥ III. Re-operation was necessary in 0.7% of the patients. New-onset diabetes occurred postoperatively in 0.3% of patients and negligible mortality and open conversion rates were observed. CONCLUSION RCP is safe and associated with low perioperative mortality and well preserved postoperative pancreatic function, although burdened by high overall morbidity and POPF rates.
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Affiliation(s)
- Gianluca Rompianesi
- Division of Hepato-Bilio-Pancreatic, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy.
| | - Roberto Montalti
- Division of Hepato-Bilio-Pancreatic, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Mariano C Giglio
- Division of Hepato-Bilio-Pancreatic, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Emanuele Caruso
- Division of Hepato-Bilio-Pancreatic, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Carlo Dl Ceresa
- Nuffield Department of Surgical Sciences, University of Oxford, UK
| | - Roberto I Troisi
- Division of Hepato-Bilio-Pancreatic, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
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14
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Rompianesi G, Pegoraro F, Ceresa CDL, Montalti R, Troisi RI. Artificial intelligence in the diagnosis and management of colorectal cancer liver metastases. World J Gastroenterol 2022; 28:108-122. [PMID: 35125822 PMCID: PMC8793013 DOI: 10.3748/wjg.v28.i1.108] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/12/2021] [Accepted: 12/25/2021] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) is the third most common malignancy worldwide, with approximately 50% of patients developing colorectal cancer liver metastasis (CRLM) during the follow-up period. Management of CRLM is best achieved via a multidisciplinary approach and the diagnostic and therapeutic decision-making process is complex. In order to optimize patients' survival and quality of life, there are several unsolved challenges which must be overcome. These primarily include a timely diagnosis and the identification of reliable prognostic factors. Furthermore, to allow optimal treatment options, a precision-medicine, personalized approach is required. The widespread digitalization of healthcare generates a vast amount of data and together with accessible high-performance computing, artificial intelligence (AI) technologies can be applied. By increasing diagnostic accuracy, reducing timings and costs, the application of AI could help mitigate the current shortcomings in CRLM management. In this review we explore the available evidence of the possible role of AI in all phases of the CRLM natural history. Radiomics analysis and convolutional neural networks (CNN) which combine computed tomography (CT) images with clinical data have been developed to predict CRLM development in CRC patients. AI models have also proven themselves to perform similarly or better than expert radiologists in detecting CRLM on CT and magnetic resonance scans or identifying them from the noninvasive analysis of patients' exhaled air. The application of AI and machine learning (ML) in diagnosing CRLM has also been extended to histopathological examination in order to rapidly and accurately identify CRLM tissue and its different histopathological growth patterns. ML and CNN have shown good accuracy in predicting response to chemotherapy, early local tumor progression after ablation treatment, and patient survival after surgical treatment or chemotherapy. Despite the initial enthusiasm and the accumulating evidence, AI technologies' role in healthcare and CRLM management is not yet fully established. Its limitations mainly concern safety and the lack of regulation and ethical considerations. AI is unlikely to fully replace any human role but could be actively integrated to facilitate physicians in their everyday practice. Moving towards a personalized and evidence-based patient approach and management, further larger, prospective and rigorous studies evaluating AI technologies in patients at risk or affected by CRLM are needed.
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Affiliation(s)
- Gianluca Rompianesi
- Division of Hepato-Bilio-Pancreatic, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples 80125, Italy
| | - Francesca Pegoraro
- Division of Hepato-Bilio-Pancreatic, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples 80125, Italy
| | - Carlo DL Ceresa
- Department of Hepato-Pancreato-Biliary Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9ES, United Kingdom
| | - Roberto Montalti
- Division of Hepato-Bilio-Pancreatic, Minimally Invasive and Robotic Surgery, Department of Public Health, Federico II University Hospital, Naples 80125, Italy
| | - Roberto Ivan Troisi
- Division of Hepato-Bilio-Pancreatic, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples 80125, Italy
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15
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Troisi RI, Alagia M, Nasto RA, Rompianesi G. Robotic pancreaticoduodenectomy with biodegradable ductal stenting (Archimedes BPS®). Surg Oncol 2022; 40:101706. [PMID: 35030411 DOI: 10.1016/j.suronc.2021.101706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 12/28/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Postoperative Pancreatic Fistula (POPF) development remains a challenge after pancreaticoduodenectomy, occurring in 3-45% of cases [1]. The placement of a trans-anastomotic Wirsung stent is usually done in high-risk patients to decrease incidence and severity of POPF. METHODS Herein, we present a fully robotic pancreaticoduodenectomy with a biodegradable ductal stent interposition in a 47 y.o. female with a main duct IPMN of the pancreatic head and a fistula risk score of 6 (Moderate-risk). VIDEO After gastrocolic ligament division and hepatic flexure and duodenum mobilization, the loco-regional lymphadenectomy was performed. Following gastric transection with endo-GIA, the bile duct and gastroduodenal artery have been divided, and the cholecystectomy performed. The neck of the pancreas has been transected, the jejunum divided with endo-GIA and mobilized from the Treitz ligament, and the uncinate process dissected from the mesenteric vessels. A Blumgart anastomosis has been performed between the soft-texture pancreatic stump and the jejunal loop with the interposition of a 6 Fr/60 mm long, medium degrading stent (20 days) in the 2 mm duct (Archimedes BPS®, AMG Int., Winsen-Germany). The hepatico-jejunostomy and gastro-jejunostomy have been performed distally on the same loop. Three abdominal drains have been positioned. RESULTS Surgery lasted 480 min, with 175 mls blood loss. The patient postoperatively developed a biochemical leak and was discharged home by day 12. She was readmitted a month later for an amylase-negative intra-abdominal abscess that was successfully treated with percutaneous drainage. CONCLUSION Biodegradable pancreatic stent positioning could be an effective strategy in reducing POPF occurrence in high-risk patients.
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Affiliation(s)
- Roberto I Troisi
- Division of Hepatobiliary and Pancreatic Surgery, Federico II University Hospital, Naples, Italy
| | - Mariantonietta Alagia
- Division of Hepatobiliary and Pancreatic Surgery, Federico II University Hospital, Naples, Italy
| | - Riccardo A Nasto
- Division of Hepatobiliary and Pancreatic Surgery, Federico II University Hospital, Naples, Italy
| | - Gianluca Rompianesi
- Division of Hepatobiliary and Pancreatic Surgery, Federico II University Hospital, Naples, Italy.
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16
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Rompianesi G, Di Martino M, Gordon-Weeks A, Montalti R, Troisi R. Liquid biopsy in cholangiocarcinoma: Current status and future perspectives. World J Gastrointest Oncol 2021; 13:332-350. [PMID: 34040697 PMCID: PMC8131901 DOI: 10.4251/wjgo.v13.i5.332] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/02/2021] [Accepted: 03/31/2021] [Indexed: 02/06/2023] Open
Abstract
Cholangiocarcinoma (CCA) are a heterogeneous group of tumors in terms of aetiology, natural history, morphological subtypes, molecular alterations and management, but all sharing complex diagnosis, management, and poor prognosis. Several mutated genes and epigenetic changes have been detected in CCA, with the potential to identify diagnostic and prognostic biomarkers and therapeutic targets. Accessing tumoral components and genetic material is therefore crucial for the diagnosis, management and selection of targeted therapies; but sampling tumor tissue, when possible, is often risky and difficult to be repeated at different time points. Liquid biopsy (LB) represents a way to overcome these issues and comprises a diverse group of methodologies centering around detection of tumor biomarkers from fluid samples. Compared to the traditional tissue sampling methods LB is less invasive and can be serially repeated, allowing a real-time monitoring of the tumor genetic profile or the response to therapy. In this review, we analysis the current evidence on the possible roles of LB (circulating DNA, circulating RNA, exosomes, cytokines) in the diagnosis and management of patients affected by CCA.
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Affiliation(s)
- Gianluca Rompianesi
- Hepato-Bilio-Pancreatic, Minimally Invasive and Robotic Surgery Unit, Department of Clinical Medicine and Surgery, Federico II University Hospital, Napoli 80131, Italy
| | - Marcello Di Martino
- Hepato-Bilio-Pancreatic Surgery Unit, Department of General and Digestive Surgery, Hospital Universitario La Princesa, Madrid 28006, Spain
| | - Alex Gordon-Weeks
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford OX3 9DU, United Kingdom
| | - Roberto Montalti
- Hepato-Bilio-Pancreatic, Minimally Invasive and Robotic Surgery Unit, Department of Clinical Medicine and Surgery, Federico II University Hospital, Napoli 80131, Italy
| | - Roberto Troisi
- Hepato-Bilio-Pancreatic, Minimally Invasive and Robotic Surgery Unit, Department of Clinical Medicine and Surgery, Federico II University Hospital, Napoli 80131, Italy
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17
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Rompianesi G, Shankar S, Reddy S, Silva M, Soonawalla Z, Friend PJ. Caught in the crossfire: hepato-bilio-pancreatic cancer surgery in the midst of COVID-19. Br J Surg 2020; 107:e309-e310. [PMID: 32567691 PMCID: PMC7362061 DOI: 10.1002/bjs.11764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 05/13/2020] [Indexed: 11/29/2022]
Affiliation(s)
- G Rompianesi
- Hepato-bilio-pancreatic Surgery Unit, Oxford University Hospitals NHS Foundation Trust
| | - S Shankar
- Nuffield Department of Surgical Sciences, University of Oxford
| | - S Reddy
- Hepato-bilio-pancreatic Surgery Unit, Oxford University Hospitals NHS Foundation Trust
| | - M Silva
- Hepato-bilio-pancreatic Surgery Unit, Oxford University Hospitals NHS Foundation Trust
| | - Z Soonawalla
- Hepato-bilio-pancreatic Surgery Unit, Oxford University Hospitals NHS Foundation Trust
| | - P J Friend
- Nuffield Department of Surgical Sciences, University of Oxford
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Troisi RI, Pegoraro F, Giglio MC, Rompianesi G, Berardi G, Tomassini F, De Simone G, Aprea G, Montalti R, De Palma GD. Robotic approach to the liver: Open surgery in a closed abdomen or laparoscopic surgery with technical constraints? Surg Oncol 2019; 33:239-248. [PMID: 31759794 DOI: 10.1016/j.suronc.2019.10.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 10/24/2019] [Indexed: 02/07/2023]
Abstract
The application of the minimally invasive approach has shown to be safe and effective for liver surgery and is in constant growth. The indications for laparoscopic surgery are steadily increasing across the field. In the early 2000s, robotic surgery led to some additional improvements, such as tremor filtration, instrument stability, 3D view and more comfort for the surgeon. These techniques bring in some advantages compared to the traditional OLR: less blood loss, shorter admissions, fewer adhesions, and a faster postoperative recovery and better outcomes in case of further hepatectomy for tumor recurrence has been shown. Concerning which is the best minimally invasive approach between laparoscopic and robotic surgery, the evidence is still conflicting. The latter shows good potential, since the endo-wristed instruments work similarly to the surgeon's hands, even with an intact abdominal wall. However, the technique is still under development, burdened by important costs, and limited by the lack of some instruments available for the laparoscopic approach. The paucity of universally accepted and proven data, especially concerning long-term outcomes, hampers drawing univocal acceptance at present. Furthermore, the number of variables related both to the patient and the disease further complicates the decision leading to a treatment tailored to each patient with strict selection. This review aims to explore the main differences between laparoscopic and robotic surgery, focusing on indications, operative technique and current debated clinical issues in recent literature.
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Affiliation(s)
- Roberto Ivan Troisi
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy; Department of Human Structure and Repair, Ghent University Faculty of Medicine, Belgium.
| | - Francesca Pegoraro
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
| | - Mariano Cesare Giglio
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
| | | | - Giammauro Berardi
- Department of Human Structure and Repair, Ghent University Faculty of Medicine, Belgium
| | - Federico Tomassini
- Department of Human Structure and Repair, Ghent University Faculty of Medicine, Belgium
| | - Giuseppe De Simone
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
| | - Giovanni Aprea
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
| | - Roberto Montalti
- Department of Public Health, Federico II University Naples, Italy
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
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Rompianesi G, Ravikumar R, Jose S, Allison M, Athale A, Creamer F, Gunson B, Manas D, Monaco A, Mirza D, Owen N, Roberts K, Sen G, Srinivasan P, Wigmore S, Fusai G, Fernando B, Burroughs A, Tsochatzis E. Incidence and outcome of colorectal cancer in liver transplant recipients: A national, multicentre analysis on 8115 patients. Liver Int 2019; 39:353-360. [PMID: 30129181 DOI: 10.1111/liv.13947] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 08/02/2018] [Accepted: 08/16/2018] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS De novo malignancies after liver transplantation represent one of the leading causes of death in the long-term. It remains unclear whether liver transplant recipients have an increased risk of colorectal cancer and whether this negatively impacts on survival, particularly in those patients affected by primary sclerosing cholangitis and ulcerative colitis. METHODS In this national multicentre cohort retrospective study, the incidence of colorectal cancer in 8115 evaluable adult patients undergoing a liver transplantation between 1 January 1990 and 31 December 2010 was compared to the incidence in the general population through standardised incidence ratios. RESULTS Fifty-two (0.6%) cases of colorectal cancer were identified at a median of 5.6 years postliver transplantation, predominantly grade 2 (76.9%) and stage T3 (50%) at diagnosis. The incidence rate of colorectal cancer in the whole liver transplant population was similar to the general UK population (SIR: 0.92), but significantly higher (SIR: 7.0) in the group of patients affected by primary sclerosing cholangitis/ulcerative colitis. One-, five- and ten-year survival rates from colorectal cancer diagnosis were 71%, 48% and 31%, respectively, and the majority of colorectal cancer patients died of cancer-specific causes. CONCLUSIONS Liver transplantation alone is not associated with an increased risk of colorectal cancer development. The primary sclerosing cholangitis/ulcerative colitis liver transplant population showed a significantly higher risk of colorectal cancer development than the general population, with a high proportion of advanced stage at diagnosis and a reduced patient survival.
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Affiliation(s)
- Gianluca Rompianesi
- Sheila Sherlock Liver Unit, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Reena Ravikumar
- Sheila Sherlock Liver Unit, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Sophie Jose
- Research Department of Infection and Population Health, University College London, London, UK
| | - Michael Allison
- Cambridge Transplant Unit, Cambridge Biomedical Research Centre, Cambridge University Hospitals, Cambridge, UK
| | - Anuja Athale
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Felicity Creamer
- Department of HPB and Transplant Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Bridget Gunson
- The Liver Unit, University Hospitals Birmingham and NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Derek Manas
- Institute of Transplantation, Freeman Hospital, Newcastle, UK
| | - Andrea Monaco
- Sheila Sherlock Liver Unit, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Darius Mirza
- The Liver Unit, University Hospitals Birmingham and NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Nicola Owen
- Cambridge Transplant Unit, Cambridge Biomedical Research Centre, Cambridge University Hospitals, Cambridge, UK
| | - Keith Roberts
- The Liver Unit, University Hospitals Birmingham and NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK
| | - Gourab Sen
- Institute of Transplantation, Freeman Hospital, Newcastle, UK
| | | | - Stephen Wigmore
- Department of HPB and Transplant Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Giuseppe Fusai
- Sheila Sherlock Liver Unit, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Bimbi Fernando
- Sheila Sherlock Liver Unit, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Andrew Burroughs
- Sheila Sherlock Liver Unit, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
| | - Emmanuel Tsochatzis
- Sheila Sherlock Liver Unit, UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical School; Department of Surgery; Royal Free Hospital Rowland Hill Street London UK NW3 2PF
| | - Thomas P A Debray
- Julius Center for Health Sciences and Primary Care; Cochrane Netherlands; PO Box 85500 3508 GA Utrecht Utrecht Netherlands
| | - Gianluca Rompianesi
- University of Modena and Reggio Emilia; International Doctorate School in Clinical and Experimental Medicine; Modena Italy
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21
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Rompianesi G, Hann A, Komolafe O, Pereira SP, Davidson BR, Gurusamy KS. Serum amylase and lipase and urinary trypsinogen and amylase for diagnosis of acute pancreatitis. Cochrane Database Syst Rev 2017; 4:CD012010. [PMID: 28431198 PMCID: PMC6478262 DOI: 10.1002/14651858.cd012010.pub2] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The treatment of people with acute abdominal pain differs if they have acute pancreatitis. It is important to know the diagnostic accuracy of serum amylase, serum lipase, urinary trypsinogen-2, and urinary amylase for the diagnosis of acute pancreatitis, so that an informed decision can be made as to whether the person with abdominal pain has acute pancreatitis. There is currently no Cochrane review of the diagnostic test accuracy of serum amylase, serum lipase, urinary trypsinogen-2, and urinary amylase for the diagnosis of acute pancreatitis. OBJECTIVES To compare the diagnostic accuracy of serum amylase, serum lipase, urinary trypsinogen-2, and urinary amylase, either alone or in combination, in the diagnosis of acute pancreatitis in people with acute onset of a persistent, severe epigastric pain or diffuse abdominal pain. SEARCH METHODS We searched MEDLINE, Embase, Science Citation Index Expanded, National Institute for Health Research (NIHR HTA and DARE), and other databases until March 2017. We searched the references of the included studies to identify additional studies. We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively. We also performed a 'related search' and 'citing reference' search in MEDLINE and Embase. SELECTION CRITERIA We included all studies that evaluated the diagnostic test accuracy of serum amylase, serum lipase, urinary trypsinogen-2, and urinary amylase for the diagnosis of acute pancreatitis. We excluded case-control studies because these studies are prone to bias. We accepted any of the following reference standards: biopsy, consensus conference definition, radiological features of acute pancreatitis, diagnosis of acute pancreatitis during laparotomy or autopsy, and organ failure. At least two review authors independently searched and screened the references located by the search to identify relevant studies. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from the included studies. The thresholds used for the diagnosis of acute pancreatitis varied in the trials, resulting in sparse data for each index test. Because of sparse data, we used -2 log likelihood values to determine which model to use for meta-analysis. We calculated and reported the sensitivity, specificity, post-test probability of a positive and negative index test along with 95% confidence interval (CI) for each cutoff, but have reported only the results of the recommended cutoff of three times normal for serum amylase and serum lipase, and the manufacturer-recommended cutoff of 50 mg/mL for urinary trypsinogen-2 in the abstract. MAIN RESULTS Ten studies including 5056 participants met the inclusion criteria for this review and assessed the diagnostic accuracy of the index tests in people presenting to the emergency department with acute abdominal pain. The risk of bias was unclear or high for all of the included studies. The study that contributed approximately two-thirds of the participants included in this review was excluded from the results of the analysis presented below due to major concerns about the participants included in the study. We have presented only the results where at least two studies were included in the analysis.Serum amylase, serum lipase, and urinary trypsinogen-2 at the standard threshold levels of more than three times normal for serum amylase and serum lipase, and a threshold of 50 ng/mL for urinary trypsinogen-2 appear to have similar sensitivities (0.72 (95% CI 0.59 to 0.82); 0.79 (95% CI 0.54 to 0.92); and 0.72 (95% CI 0.56 to 0.84), respectively) and specificities (0.93 (95% CI 0.66 to 0.99); 0.89 (95% CI 0.46 to 0.99); and 0.90 (95% CI 0.85 to 0.93), respectively). At the median prevalence of 22.6% of acute pancreatitis in the studies, out of 100 people with positive test, serum amylase (more than three times normal), serum lipase (more than three times normal), and urinary trypsinogen (more than 50 ng/mL), 74 (95% CI 33 to 94); 68 (95% CI 21 to 94); and 67 (95% CI 57 to 76) people have acute pancreatitis, respectively; out of 100 people with negative test, serum amylase (more than three times normal), serum lipase (more than three times normal), and urinary trypsinogen (more than 50 ng/mL), 8 (95% CI 5 to 12); 7 (95% CI 3 to 15); and 8 (95% CI 5 to 13) people have acute pancreatitis, respectively. We were not able to compare these tests formally because of sparse data. AUTHORS' CONCLUSIONS As about a quarter of people with acute pancreatitis fail to be diagnosed as having acute pancreatitis with the evaluated tests, one should have a low threshold to admit the patient and treat them for acute pancreatitis if the symptoms are suggestive of acute pancreatitis, even if these tests are normal. About 1 in 10 patients without acute pancreatitis may be wrongly diagnosed as having acute pancreatitis with these tests, therefore it is important to consider other conditions that require urgent surgical intervention, such as perforated viscus, even if these tests are abnormal.The diagnostic performance of these tests decreases even further with the progression of time, and one should have an even lower threshold to perform additional investigations if the symptoms are suggestive of acute pancreatitis.
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Affiliation(s)
- Gianluca Rompianesi
- University of Modena and Reggio EmiliaInternational Doctorate School in Clinical and Experimental MedicineModenaItaly
| | | | | | - Stephen P Pereira
- Royal Free Hospital CampusUCL Institute for Liver and Digestive HealthUpper 3rd FloorLondonUKNW3 2PF
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryPond StreetLondonUKNW3 2QG
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De Pietri L, Bianchini M, Rompianesi G, Bertellini E, Begliomini B. Thromboelastographic reference ranges for a cirrhotic patient population undergoing liver transplantation. World J Transplant 2016; 6:583-593. [PMID: 27683637 PMCID: PMC5036128 DOI: 10.5500/wjt.v6.i3.583] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 06/21/2016] [Accepted: 08/16/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To describe the thromboelastography (TEG) “reference” values within a population of liver transplant (LT) candidates that underline the differences from healthy patients.
METHODS Between 2000 and 2013, 261 liver transplant patients with a model for end-stage liver disease (MELD) score between 15 and 40 were studied. In particular the adult patients (aged 18-70 years) underwent to a first LT with a MELD score between 15 and 40 were included, while all patients with acute liver failure, congenital bleeding disorders, and anticoagulant and/or antiplatelet drug use were excluded. In this population of cirrhotic patients, preoperative haematological and coagulation laboratory tests were collected, and the pretransplant thromboelastographic parameters were studied and compared with the parameters measured in a previously studied population of 40 healthy subjects. The basal TEG parameters analysed in the cirrhotic population of liver candidates were as follows: Reaction time (r), coagulation time (k), Angle-Rate of polymerization of clot (αAngle), Maximum strenght of clot (MA), Amplitudes of the TEG tracing at 30 min and 60 min after MA is measured (A30 and A60), and Fibrinolysis at 30 and 60 min after MA (Ly30 and Ly60). The possible correlation between the distribution of the reference range and the gender, age, MELD score (higher or lower than 20) and indications for transplantation (liver pathology) were also investigated. In particular, a MELD cut-off value of 20 was chosen to verify the possible correlation between the thromboelastographic reference range and MELD score.
RESULTS Most of the TEG reference values from patients with end-stage liver disease were significantly different from those measured in the healthy population and were outside the suggested normal ranges in up to 79.3% of subjects. Wide differences were found among all TEG variables, including r (41.5% of the values), k (48.6%), α (43.7%), MA (79.3%), A30 (74.4%) and A60 (80.9%), indicating a prevailing trend to hypocoagulability. The differences between the mean TEG values obtained from healthy subjects and the cirrhotic population were statistically significant for r (P = 0.039), k (P < 0.001), MA (P < 0.001), A30 (P < 0.001), A60 (P < 0.001) and Ly60 (P = 0.038), indicating slower and less stable clot formation in the cirrhotic patients. In the cirrhotic population, 9.5% of patients had an r value shorter than normal, indicating a tendency for faster clot formation. Within the cirrhotic patient population, gender, age and the presence of hepatocellular carcinoma or alcoholic cirrhosis were not significantly associated with greater clot firmness or enhanced whole blood clot formation, whereas greater clot strength was associated with a MELD score < 20, hepatitis C virus and cholestatic-related cirrhosis (P < 0.001; P = 0.013; P < 0.001).
CONCLUSION The range and distribution of TEG values in cirrhotic patients differ from those of healthy subjects, suggesting that a specific thromboelastographic reference range is required for liver transplant candidates.
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De Pietri L, Serra V, Preziosi G, Rompianesi G, Begliomini B. Perioperative effects of high doses of intraoperative thymoglobulin induction in liver transplantation. World J Transplant 2015; 5:320-328. [PMID: 26722660 PMCID: PMC4689943 DOI: 10.5500/wjt.v5.i4.320] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 10/06/2015] [Accepted: 11/25/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To describe our single-centre experience in liver transplantation (LT) with the infusion of high perioperative thymoglobulin doses. The optimal dosage and timing of thymoglobulin® [antithymocyte globulin (ATG)] administration during LT remains controversial. Cytokine release syndrome, haemolytic anaemia, thrombocytopenia, neutropenia, fever and serum sickness are potential adverse effects associated with ATG infusion.
METHODS: Between December 2009 and December 2010, 16 adult non-randomized patients (ATG group), receiving a liver graft from a deceased donor, received an intraoperative infusion (4-6 h infusion) of thymoglobulin (3 mg/kg, ATG: Thymoglobuline®). These patients were compared (case control approach) with 16 patients who had a liver transplant without ATG treatment (control group) to evaluate the possible effects of intraoperative ATG infusion. The matching parameters were: Sex, recipient age (± 5 years), LT indication including viral status, MELD score (± 5 points), international normalized ratio and platelet count (as close as possible). The exclusion criteria for both groups included the following: Multi-organ or living donor transplant, immunosuppressive therapy before transplantation, contraindications to the administration of any thymocyte globulin, human immunodeficiency virus seropositivity, thrombocytopenia [platelet < 50000/μL] or leukopenia [white blood cells < 1000/μL]. The perioperative side effects (haemodynamic alterations, core temperature variations, colloids and crystalloids requirements, and surgical time) possibly related to ATG infusion and the thromboelastographic (TEG) evaluation of the ATG effects on coagulation, blood loss and blood product transfusion were analysed during the operation and the first three postoperative days.
RESULTS: Intraoperative ATG administration was associated with longer surgical procedures [560 ± 88 min vs 480 ± 83 min (control group), P = 0.013], an intraoperative core temperature more than 37 °C (50% of ATG patients vs 6.2% of control patients, P = 0.015), major intraoperative blood loss [3953 ± 3126 mL vs 1419 ± 940 mL (control group), P = 0.05], higher red blood cell [2092 ± 1856 mL ATG group vs 472 ± 632 mL (control group), P = 0.02], fresh frozen plasma [671 ± 1125 mL vs 143 ± 349 mL (control group), P = 0.015], and platelet [374 ± 537 mL vs 15.6 ± 62.5 mL (control group), P = 0.017] transfusion, and a higher requirement for catecholamines (0.08 ± 0.07 μg/kg per minutes vs 0.01 ± 0.38 μg/kg per minutes, respectively, in the ATG and control groups) for haemodynamic support. The TEG tracings changed to a straight line during ATG infusion (preanhepatic and anhepatic phases) in 81% of the patients from the ATG group compared to 6.25% from the control group (P < 0.001). Patients from the ATG group compared to controls had higher post-op core temperatures (38 °C ± 1.0 °C vs 37.3 °C ± 0.5 °C; P = 0.02), an increased need of noradrenaline (43.7% vs 6.25%, P = 0.037), received more platelet transfusions (31.5% vs 0%, P = 0.04) and required continuous renal replacement therapy (4 ATG patients vs none in the control group; P = 0.10). ATG infusion was considered the cause of a fatal anaphylactic shock and of a suspected adverse reaction that led to intravascular haemolysis and acute renal failure.
CONCLUSION: The side effects and the coagulation imbalance observed in patients receiving a high dosage of ATG suggest caution in the use of thymoglobulin during LT.
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Rompianesi G, Montalti R, Cautero N, De Ruvo N, Stafford A, Bronzoni C, Ballarin R, De Pietri L, Di Benedetto F, Gerunda GE. Neurological complications after liver transplantation as a consequence of immunosuppression: univariate and multivariate analysis of risk factors. Transpl Int 2015; 28:864-9. [PMID: 25790037 DOI: 10.1111/tri.12564] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 12/30/2014] [Accepted: 03/15/2015] [Indexed: 12/17/2022]
Abstract
Neurological complications (NCs) can frequently and significantly affect morbidity and mortality of liver transplant (LT) recipients. We analysed incidence, risk factors, outcome and impact of the immunosuppressive therapy on NC development after LT. We analysed 478 LT in 440 patients, and 93 (19.5%) were followed by NCs. The average LOS was longer in patients experiencing NCs. The 1-, 3- and 5-year graft survival and patient survival were similar in patients with or without a NC. Multivariate analysis showed the following as independent risk factors for NC: a MELD score ≥20 (OR = 1.934, CI = 1.186-3.153) and an immunosuppressive regimen based on calcineurin inhibitors (CNIs) (OR = 1.669, CI = 1.009-2.760). Among patients receiving an everolimus-based immunosuppression, the 7.1% developed NCs, vs. the 16.9% in those receiving a CNI (P = 0.039). There was a 1-, 3- and 5-year NC-free survival of 81.7%, 81.1% and 77.7% in patients receiving a CNI-based regimen and 95.1%, 93.6% and 92.7% in those not receiving a CNI-based regimen (P < 0.001). In patients undergoing a LT and presenting with nonmodifiable risk factors for developing NCs, an immunosuppressive regimen based on CNIs is likely to result in a higher rate of NCs compared to mTOR inhibitors.
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Affiliation(s)
- Gianluca Rompianesi
- Liver Transplant Centre, Azienda Ospedaliero-Universitaria di Modena Policlinico, Modena, Italy
| | - Roberto Montalti
- Liver Transplant Centre, Azienda Ospedaliero-Universitaria di Modena Policlinico, Modena, Italy
| | - Nicola Cautero
- Liver Transplant Centre, Azienda Ospedaliero-Universitaria di Modena Policlinico, Modena, Italy
| | - Nicola De Ruvo
- Liver Transplant Centre, Azienda Ospedaliero-Universitaria di Modena Policlinico, Modena, Italy
| | | | - Carolina Bronzoni
- General Surgery, Azienda Ospedaliero-Universitaria di Modena Policlinico, Modena, Italy
| | - Roberto Ballarin
- Liver Transplant Centre, Azienda Ospedaliero-Universitaria di Modena Policlinico, Modena, Italy
| | - Lesley De Pietri
- Division of Anaesthesiology and Intensive Care Unit, Azienda Ospedaliero-Universitaria di Modena Policlinico, Modena, Italy
| | - Fabrizio Di Benedetto
- Liver Transplant Centre, Azienda Ospedaliero-Universitaria di Modena Policlinico, Modena, Italy
| | - Giorgio E Gerunda
- General Surgery, Azienda Ospedaliero-Universitaria di Modena Policlinico, Modena, Italy
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Montalti R, Rompianesi G, Di Benedetto F, Masetti M, De Ruvo N, Ballarin R, Guerrini GP, Smerieri N, Iemmolo RM, De Pietri L, Gerunda GE. Liver transplantation utilizing grafts from donors with genitourinary cancer detected prior to liver implantation. Transplant Proc 2014; 41:1275-7. [PMID: 19460537 DOI: 10.1016/j.transproceed.2009.03.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Expansion of the donor pool has led to reconsideration of selection criteria to obtain the largest number of grafts without compromising recipient outcomes. This reconsideration concerns the utilization of donors with malignancies. Herein we have analyzed the outcomes, survivals, and risks of cancer transmission among patients who received a liver transplant from a donor with a genitourinary malignancy. Six of 363 patients (1.5%) who underwent transplantation at our center received an organ from a donor with a genitourinary cancer which was detected prior to the surgical harvest. Donors affected by low-grade renal cell carcinoma (Fuhrman grade 1 or 2) or low-grade intraprostatic prostate carcinoma (Gleason score <or= 6) were classified as "standard risk" and utilized pending informed consent. Four of 6 patients (66.6%) succumbed, but none consequent to a neoplastic disease. The mean follow-up was 12 +/- 8.1 months; in no patient was there evidence of transmission of a donor malignancy. Despite a relatively high risk of liver metastases among patients with genitourinary neoplasms, the risk of tumor transmission to a liver recipient is low. It seems to be safe to utilize these donors for patients with a high risk of succumbing on the waiting list.
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Affiliation(s)
- R Montalti
- Liver and Multivisceral Transplant Centre, Azienda Ospedaliero-Universitaria-Policlinico di Modena, Modena, Italy.
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26
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Angelico M, Nardi A, Romagnoli R, Marianelli T, Corradini SG, Tandoi F, Gavrila C, Salizzoni M, Pinna AD, Cillo U, Gridelli B, De Carlis LG, Colledan M, Gerunda GE, Costa AN, Strazzabosco M, Cillo U, Fagiuoli S, Strazzabosco M, Caraceni P, Toniutto P, Nanni Costa A, Salizzoni TM, Romagnoli R, Bertolotti G, Patrono D, De Carlis L, Slim A, Mangoni J, Rossi G, Caccamo L, Antonelli B, Mazzaferro V, Regalia E, Sposito C, Colledan M, Corno V, Tagliabue F, Marin S, Cillo U, Vitale A, Gringeri E, Donataccio M, Donataccio D, Baccarani U, Lorenzin D, Bitetto D, Valente U, Gelli M, Cupo P, Gerunda G, Rompianesi G, Pinna A, Grazi G, Cucchetti A, Zanfi C, Risaliti A, Faraci M, Tisone G, Anselmo A, Lenci I, Sforza D, Agnes S, Di Mugno M, Avolio A, Ettorre G, Miglioresi L, Vennarecci G, Berloco P, Rossi M, Ginanni Corradini S, Molinaro A, Calise F, Scuderi V, Cuomo O, Migliaccio C, Lupo L, Notarnicola G, Gridelli B, Volpes R, Li Petri S, Zamboni F, Carbotta G, Dedola S, Nardi A, Marianelli T, Gavrila C, Ricci A, Vespasiano F. A Bayesian methodology to improve prediction of early graft loss after liver transplantation derived from the liver match study. Dig Liver Dis 2014; 46:340-7. [PMID: 24411484 DOI: 10.1016/j.dld.2013.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 11/07/2013] [Accepted: 11/10/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND To generate a robust predictive model of Early (3 months) Graft Loss after liver transplantation, we used a Bayesian approach to combine evidence from a prospective European cohort (Liver-Match) and the United Network for Organ Sharing registry. METHODS Liver-Match included 1480 consecutive primary liver transplants performed from 2007 to 2009 and the United Network for Organ Sharing a time-matched series of 9740 transplants. There were 173 and 706 Early Graft Loss, respectively. Multivariate analysis identified as significant predictors of Early Graft Loss: donor age, donation after cardiac death, cold ischaemia time, donor body mass index and height, recipient creatinine, bilirubin, disease aetiology, prior upper abdominal surgery and portal thrombosis. RESULTS A Bayesian Cox model was fitted to Liver-Match data using the United Network for Organ Sharing findings as prior information, allowing to generate an Early Graft Loss-Donor Risk Index and an Early Graft Loss-Recipient Risk Index. A Donor-Recipient Allocation Model, obtained by adding Early Graft Loss-Donor Risk Index to Early Graft Loss-Recipient Risk Index, was then validated in a distinct United Network for Organ Sharing (year 2010) cohort including 2964 transplants. Donor-Recipient Allocation Model updating using the independent Turin Transplant Centre dataset, allowed to predict Early Graft Loss with good accuracy (c-statistic: 0.76). CONCLUSION Donor-Recipient Allocation Model allows a reliable donor and recipient-based Early Graft Loss prediction. The Bayesian approach permits to adapt the original Donor-Recipient Allocation Model by incorporating evidence from other cohorts, resulting in significantly improved predictive capability.
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Affiliation(s)
- Mario Angelico
- Liver Unit, Tor Vergata University, Rome, Italy; Italian Association for the Study of the Liver (AISF), Italian National Transplant Centre (CNT) and Italian Liver Transplant Centres, Italy
| | | | - Renato Romagnoli
- Liver Transplant Unit, Azienda Ospedaliera Città della Salute e della Scienza, University of Turin, Italy; Italian Association for the Study of the Liver (AISF), Italian National Transplant Centre (CNT) and Italian Liver Transplant Centres, Italy.
| | - Tania Marianelli
- Liver Unit, Tor Vergata University, Rome, Italy; Italian Association for the Study of the Liver (AISF), Italian National Transplant Centre (CNT) and Italian Liver Transplant Centres, Italy
| | - Stefano Ginanni Corradini
- Gastroenterology Unit, La Sapienza University, Rome, Italy; Italian Association for the Study of the Liver (AISF), Italian National Transplant Centre (CNT) and Italian Liver Transplant Centres, Italy
| | - Francesco Tandoi
- Liver Transplant Unit, Azienda Ospedaliera Città della Salute e della Scienza, University of Turin, Italy
| | - Caius Gavrila
- Department of Mathematics, Tor Vergata University, Rome, Italy
| | - Mauro Salizzoni
- Liver Transplant Unit, Azienda Ospedaliera Città della Salute e della Scienza, University of Turin, Italy
| | | | - Umberto Cillo
- Liver Transplant Unit, Università of Padua, Italy; Italian Association for the Study of the Liver (AISF), Italian National Transplant Centre (CNT) and Italian Liver Transplant Centres, Italy
| | | | | | | | | | | | - Mario Strazzabosco
- Digestive Disease Section, University of Milan Bicocca, Milan, Italy; Yale University Liver Centre, New Haven, USA; Italian Association for the Study of the Liver (AISF), Italian National Transplant Centre (CNT) and Italian Liver Transplant Centres, Italy
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Pignatti M, Gerunda GE, Rompianesi G, De Ruvo N, Di Benedetto F, Codeluppi M, Bonucchi D, Pacchioni L, Loschi P, Malaventura C, De Santis G. Treatment of wounds colonized by multidrug resistant organisms in immune-compromised patients: a retrospective case series. Patient Saf Surg 2013; 7:28. [PMID: 24139428 PMCID: PMC3847491 DOI: 10.1186/1754-9493-7-28] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 08/26/2013] [Indexed: 11/26/2022] Open
Abstract
Background Immune-compromised patients incur a high risk of surgical wound dehiscence and colonization by multidrug resistant organisms. Common treatment has been debridement and spontaneous secondary healing. We report on the results obtained in nine such patients whose wounds were treated by debridement, negative pressure dressing and direct closure. Methods All immune-compromised patients referred to our Institution between March 1, 2010 and November 30, 2011 for dehiscent abdominal wounds growing multidrug resistant organisms were treated by serial wound debridements and negative pressure dressing. They were primarily closed, despite positive microbiological cultures, when clinical appearance was satisfactory. As a comparison, records from patients treated between March 1, 2008 and February 28, 2010 who, according to our Institution’s policy at that time, had been left to heal by secondary intention, were retrieved and examined. Results Nine patients were treated by direct wound closure, five had been treated previously by secondary intention healing. Overall, ten patients had received liver transplant, 1 kidney transplant, 1 was HIV infected, 1 suffered from multi-organ failure, 1 was undergoing hemodialysis. Wound dehiscence involved skin and subcutaneous layers in all patients, in two the muscular layer was also involved. Mean healing time was significantly shorter in patients treated more recently by primary intention in comparison with historical patients (28 vs 81 days). The only complication observed was a small superficial abscess that developed around a non-absorbable stitch 10 months after closure in a patient treated by primary closure. Conclusions According to our results, fast healing can be safely obtained by closure of a clinically healthy wound, despite growth of multidrug resistant organisms, even in immune-compromised patients.
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Affiliation(s)
- Marco Pignatti
- Department of Plastic and Reconstructive Surgery, Policlinico of Modena,University of Modena and Reggio Emilia, Via del Pozzo 71, Modena I - 41124, Italy.
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Roat E, De Biasi S, Bertoncelli L, Rompianesi G, Nasi M, Gibellini L, Pinti M, Del Giovane C, Zanella A, Di Benedetto F, Gerunda GE, Cossarizza A. Immunological advantages of everolimus versus cyclosporin A in liver-transplanted recipients, as revealed by polychromatic flow cytometry. Cytometry A 2012; 81:303-11. [PMID: 22311717 DOI: 10.1002/cyto.a.22019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2011] [Revised: 11/29/2011] [Accepted: 01/05/2012] [Indexed: 12/17/2022]
Abstract
Several immunosuppressive drugs with different mechanisms of action are available to inhibit organ rejection after transplant. We analyzed different phenotypic and functional immunological parameters in liver-transplanted patients who received cyclosporin A (CsA) or Everolimus (Evr). In peripheral blood mononuclear cells (PBMC) from 29 subjects receiving a liver transplant and treated with two different immunosuppressive regimens, we analyzed T cell activation and differentiation, regulatory T cells (Tregs) and Tregs expressing homing receptors such as the chemokine receptor CXCR3. T cell polyfunctionality was studied by stimulating cells with the superantigen staphylococcal enterotoxin B (SEB), and measuring the simultaneous production of interleukin (IL)-2 and interferon (IFN)-γ, along with the expression of a marker of cytotoxicity such as CD107a. The analyses were performed by polychromatic flow cytometry before transplantation, and at different time points, up to 220 days after transplant. Patients taking Evr had a higher percentage of total CD4⁺ and naïve CD4⁺ T cells than those treated with CsA; the percentage of CD8⁺ T cells was lower, but the frequency of naïve CD8⁺ T cells higher. Patients taking Evr showed a significantly higher percentage of Tregs, and Tregs expressing CXCR3. After stimulation with SEB, CD8⁺ T cells from Evr-treated patients displayed a lower total response, and less IFN-γ producing cells. The effects on the immune system, such as the preservation of the naïve T cell pool and the expansion of Tregs (that are extremely useful in inhibiting organ rejection), along with the higher tolerability of Evr, suggest that this drug can be safely used after liver transplantation, and likely offers immunological advantages.
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Affiliation(s)
- Erika Roat
- Department of Biomedical Sciences, University of Modena and Reggio Emilia, Modena 41125, Italy
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Montalti R, Mimmo A, Rompianesi G, Serra V, Cautero N, Ballarin R, De Ruvo N, Cunningham Gerring R, Enrico Gerunda G, Di Benedetto F. Early use of mammalian target of rapamycin inhibitors is an independent risk factor for incisional hernia development after liver transplantation. Liver Transpl 2012; 18:188-94. [PMID: 21987434 DOI: 10.1002/lt.22445] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Incisional hernias (IHs) are common complications after liver transplantation (LT) with a reported incidence of 1.7% to 34.3%. The purpose of this retrospective study was to evaluate the risk factors for IH development after LT with a focus on the role of immunosuppressive therapy during the first month after LT. We analyzed 373 patients who underwent LT and divided them into 2 groups according to their postoperative course: an IH group (121 patients or 32.4%) and a no-IH group (252 patients or 67.6%). A univariate analysis demonstrated that the following were risk factors related to IH development: male sex (P = 0.03), a body mass index ≥ 29 kg/m(2) (P = 0.005), LT after 2004 (P = 0.02), a Model for End-Stage Liver Disease (MELD) score ≥ 22 (P = 0.01), and hepatitis B virus infection (P = 0.01). The highest incidence of IHs was found in patients treated with mammalian target of rapamycin (mTOR) inhibitors (54.5%, P = 0.004). A multivariate analysis revealed male sex (P = 0.03), a pretransplant MELD score ≥ 22 (P = 0.04), and the use of mTOR inhibitors (P = 0.001) to be independent risk factors for IHs after LT. In conclusion, immunosuppressive therapy with mTOR inhibitors is an important independent risk factor for IH development after LT. To reduce the incidence of IHs, mTOR inhibitors should be avoided until the fourth month after LT unless their use is deemed to be strictly necessary.
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Affiliation(s)
- Roberto Montalti
- Liver and Multivisceral Transplant Center, University of Modena and Reggio Emilia, Modena, Italy.
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Ballarin R, Montalti R, Spaggiari M, Cautero N, De Ruvo N, Guerrini GP, Rompianesi G, Longo C, Gerunda GE, Di Benedetto F. Liver transplantation in older adults: our point of view. J Am Geriatr Soc 2011; 59:1359-61. [PMID: 21751978 DOI: 10.1111/j.1532-5415.2011.03462.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Di Benedetto F, Tarantino G, De Ruvo N, Cautero N, Montalti R, Guerrini GP, Ballarin R, Spaggiari M, Smerieri N, Serra V, Rompianesi G, D'Amico G, Mimmo A, Iemmolo RM, Codeluppi M, Cocchi S, Guaraldi G, Gerunda GE. University of Modena experience in HIV-positive patients undergoing liver transplantation. Transplant Proc 2011; 43:1114-8. [PMID: 21620066 DOI: 10.1016/j.transproceed.2011.03.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Highly effective antiretroviral therapy in the last decade has increased the survival rates of HIV-positive patients, yielding a greater number of HIV patients suffering from liver-related disease. Liver transplantation (LT) is the only curative treatment for end-stage liver disease (ESLD) associated or not with hepatocellular carcinoma (HCC). PATIENTS AND METHODS From June 2003 to September 2010, 23 patients underwent cadaveric donor LT for ESLD at our institution. Inclusion criteria followed the Italian Protocol for LT in HIV-positive patients. Immunosuppressive regimens were based on cyclosporine or tacrolimus, eventually switched to Rapamycin. RESULTS The median CD4 T-cell count was 275/mmc (range=119-924). All patients were affected by ESLD, which was associated with HCC in 14 cases. Ten patients were within the Milan criteria and four patients exceeded them but were within the San Francisco criteria. Conversion from calcineurin inhibitors (CNI) to rapamycin occurred in ten cases. Hepatitis C virus (HCV) recurrence occurred in 13/21 HCV-positive patients. Acute cellular rejection occurred in eight patients with one developing chronic cellular rejection. Overall patient and graft survivals at 80 months were 50% and 45% respectively. DISCUSSION LT in HIV-positive patients is a feasible procedure, even if in our experience was burdened by a greater incidence of complications including HCV recurrence and infection compared with HIV-negative patients.
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Affiliation(s)
- F Di Benedetto
- Liver and Multivisceral Transplant Center, University of Modena and Reggio Emilia, Modena, Italy.
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Masetti M, Montalti R, Rompianesi G, Codeluppi M, Gerring R, Romano A, Begliomini B, Di Benedetto F, Gerunda GE. Early withdrawal of calcineurin inhibitors and everolimus monotherapy in de novo liver transplant recipients preserves renal function. Am J Transplant 2010; 10:2252-62. [PMID: 20486905 DOI: 10.1111/j.1600-6143.2010.03128.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We designed a randomized trial to assess whether the early withdrawal of cyclosporine (CsA) followed by the initiation of everolimus (Evr) monotherapy in de novo liver transplantation (LT) patients would result in superior renal function compared to a CsA-based immunosuppression protocol. All patients were treated with CsA for the first 10 days and then randomized to receive Evr in combination with CsA up to day 30, then either continued on Evr monotherapy (Evr group) or maintained on CsA with/without mycophenolate mofetil (CsA group) in case of chronic kidney disease (CKD). Seventy-eight patients were randomized (Evr n = 52; CsA n = 26). The 1-year freedom from efficacy failure in Evr group was 75% versus 69.2% in CsA group, p = 0.36. There was no statistically significant difference in patient survival between the two groups. Mean modification of diet in renal disease (MDRD) was significantly better in the Evr group at 12 months (87.7 ± 26.1 vs. 59.9 ± 12.6 mL/min; p < 0.001). The incidence of CKD stage ≥ 3 (estimated glomerular filtration rate < 60 mL/min) was higher in the CsA group at 1 year (52.2% vs. 15.4%, p = 0.005). The results indicate that early withdrawal of CsA followed by Evr monotherapy in de novo LT patients is associated with an improvement in renal function, with a similar incidence of rejection and major complications.
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Affiliation(s)
- M Masetti
- Liver and Multivisceral Transplantation Center Division of Infectious Diseases, Azienda Ospedaliero-Universitaria di Modena-Policlinico, Modena, Italy.
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Montalti R, Rompianesi G, Di Benedetto F, Ballarin R, Gerring RC, Busani S, De Pietri L, De Ruvo N, Iemmolo RM, Guerrini GP, Smerieri N, Gerunda GE. Liver transplantation in patients aged 65 and over: a case-control study. Clin Transplant 2010; 24:E188-93. [PMID: 20236130 DOI: 10.1111/j.1399-0012.2010.01230.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION The average age of patients undergoing liver transplantation (LT) is consistently increasing. The aim of this case-control study is to evaluate survival and outcome of patients ≥65 yr compared to younger patients undergoing LT. MATERIALS AND METHODS From 10/00 to 4/08 we performed 330 primary LT, 31 (9.4%) of these were in patients aged 65-70. Following a case-control approach, we compared these patients with 31 patients aged between 41 and 64 yr and matched according to sex, LT indication, viral status, cadaveric/living donor, LT timing, and Model for End-Stage Liver Disease (MELD) score. RESULTS There were no statistically significant differences in demographic and surgical donor characteristics. The mean MELD score was under 18 in both groups. Post-LT complications occurred with a similar incidence in the two groups. one-, three-, and five-yr survival was 83.9%, 80.6%, and 80.6%, respectively, for the elderly group, and 80.6%, 73.8%, and 73.8%, respectively, for the young group (p = 0.61). DISCUSSION Patients aged between 65 and 70 with low MELD score who undergo LT have the same short- and middle-term survival expectancy, morbidity, and outcome quality as younger patients with the same indication and same pre-LT pathology severity, whatever they might be. Thus, chronological age alone should not deter LT workup in patients >65 and <70.
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Affiliation(s)
- R Montalti
- Liver and Multivisceral Transplant Centre, University of Modena and Reggio Emilia, Modena, Italy.
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De Pietri L, Montalti R, Begliomini B, Scaglioni G, Marconi G, Reggiani A, Di Benedetto F, Aiello S, Pasetto A, Rompianesi G, Gerunda GE. Thromboelastographic changes in liver and pancreatic cancer surgery: hypercoagulability, hypocoagulability or normocoagulability? Eur J Anaesthesiol 2010; 27:608-16. [PMID: 20389262 DOI: 10.1097/eja.0b013e328334df31] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Despite clinical and laboratory evidence of perioperative hypercoagulability, alterations in haemostasis after potentially haemorrhagic oncologic surgery are difficult to predict. This study aims to evaluate the entity, the extent and the duration of perioperative coagulative alterations following pancreas and liver oncologic surgery, by the use of both routine tests and thromboelastogram (TEG). METHODS Fifty-six patients undergoing liver (n = 38) and pancreatic (n = 18) surgery were studied. The coagulation profile was evaluated by platelet count, prothrombin time-international normalized ratio, activated partial thromboplastin time, antithrombin III and TEG at the beginning, at the end of the operation and on postoperative days 1, 3, 5 and 10. RESULTS All preoperative coagulative screening and TEG traces were normal before incision. In the postoperative period of the liver and pancreas groups, despite an increase in prothrombin time-international normalized ratio, a reduction in antithrombin III and platelet count and normal activated partial thromboplastin time and fibrinogen, TEG evidenced a normocoagulability in the liver group, with a major tendency towards hypocoagulability in the pancreas group, as evidenced by a transient increase in R-time and K-time between postoperative days 1 and 3. During the study period, four cases of pulmonary embolism, resolved with heparin infusion, were recorded, in the absence of laboratory and thromboelastographic evidence of hypercoagulability. CONCLUSION Despite laboratory tests evidencing hypocoagulability in both groups, TEG traces showed a normocoagulability in liver resections, whereas a transient thromboelastographic hypocoagulability was evident in patients undergoing pancreas surgery. The discrepancy between laboratory values and thromboelastographic variables was even more evident in patients undergoing major liver resections compared with minor ones. Our study supports the role of thromboelastography, despite its limitations, as a valuable tool for the evaluation of the perioperative whole coagulation process and hypercoagulability changes and to increase patient safety through better management of antithrombotic therapy.
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Affiliation(s)
- Lesley De Pietri
- Division of Anaesthesiology, Azienda Ospedaliero-Universitaria di Modena-Policlinico, Modena, Italy.
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Montalti R, Busani S, Masetti M, Girardis M, Di Benedetto F, Begliomini B, Rompianesi G, Rinaldi L, Ballarin R, Pasetto A, Gerunda GE. Two-stage liver transplantation: an effective procedure in urgent conditions. Clin Transplant 2010; 24:122-6. [PMID: 19843110 DOI: 10.1111/j.1399-0012.2009.01118.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Temporary portocaval shunt and total hepatectomy is a technique used in the presence of toxic liver syndrome because of fulminant hepatic failure, hepatic trauma, primary non-function (PNF), and eclampsia. We performed this technique on four patients. An indication for anhepatic state was severe hemodynamic instability in three of them. Etiologies of these three patients were as follows: PNF after liver transplantation, ischemic hepatitis after right hepatic artery embolization, and massive reperfusion syndrome during a liver transplantation. In the fourth patient, during the liver transplantation when hepatic artery was ligated, a kidney carcinoma in the donor graft was discovered. We decided to complete the hepatectomy and to construct a temporary portocaval shunt. Mean anhepatic phases were 19 h and 15 min. All patients survived the two-stage liver transplantation procedure without major complications. Our cases demonstrated that temporary portocaval shunt while awaiting urgent liver transplantation could be an effective "bridge" in selected patients who develop toxic liver syndrome; however, a short time between portocaval shunt and transplantation and careful intensive care managements are mandatory.
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Affiliation(s)
- Roberto Montalti
- Liver and Multivisceral Transplant Centre, University of Modena and Reggio Emilia, Modena, Italy
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Arzu GD, De Ruvo N, Montalti R, Masetti M, Begliomini B, Di Benedetto F, Rompianesi G, Di Sandro S, Smerieri N, D'Amico G, Vezzelli E, Iemmolo RM, Romano A, Ballarin R, Guerrini GP, De Blasiis MG, Spaggiari M, Gerunda GE. Temporary porto-caval shunt utility during orthotopic liver transplantation. Transplant Proc 2008; 40:1937-40. [PMID: 18675094 DOI: 10.1016/j.transproceed.2008.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION In liver transplantation (OLT) a porto-caval shunt is a well-defined technique practiced by many surgeons in several centers. METHODS We considered 186 cadaveric OLT patients who underwent a cavo-cavostomy-type reconstruction; they were divided into two groups: those in whom we performed a porto-caval shunt (group A) and those in whose we did not (group B). We evaluated several variables: warm and total ischemia time, intraoperative blood and fresh frozen plasma transfusions, crystalloid and colloid requirements, blood loss, operative duration, hemodynamic intraoperative changes and diuresis, length of hospital stay, and creatinine values at days 1 and 2, and at discharge day. RESULTS Total and warm ischemic time differed significantly between the two groups. Infusion of blood, fresh frozen plasma, colloid, and crystalloid did not significantly differ. Blood loss was lower, and intraoperative diuresis was not significantly increased in group A subjects. Postoperative hospitalizations were 16.5 and 17.8 days and operative times, 504 and 611 minutes in the two groups. Both cardiac index and ejection fraction values during the anhepatic phase were significantly greater among group A than group B patients. PAD at the two phases was greater in group B. The PAS was significantly different only at reperfusion time. Creatinine values were significantly different at discharge. Better survival was shown for group A patients over group B subjects. CONCLUSION The results presented herein confirmed that a porto-caval shunt during OLT was a safe, useful expedient contributing to an improved hemodynamic status and a better time distribution in the various phases of liver transplantation.
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Affiliation(s)
- G D Arzu
- Liver and Multivisceral Transplant Center, University of Modena, Modena, Italy
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Masetti M, Rompianesi G, Montalti R, Romano A, Spaggiari M, Ballarin R, Guerrini GP, Gerunda GE. Effects of everolimus monotherapy on hematological parameters and iron homeostasis in de novo liver transplant recipients: preliminary results. Transplant Proc 2008; 40:1947-9. [PMID: 18675097 DOI: 10.1016/j.transproceed.2008.05.068] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Anemia after orthotopic liver transplantation (OLT) is a common complication due to several reasons. Immunosuppressive drugs play an important role in anemia occurring at 1 month or more after OLT. Several studies describe myelosuppression immunosuppressants such as the mammalian target of rapamycin inhibitors. METHODS We performed a single-center, prospective trial consisting of a short 30-day course of cyclosporine (CsA) associated with everolimus (EVL) from postoperative day 10 (Group EVL) versus a CsA immunosuppressive regimen (Group CsA) in de novo OLT patients. We explored the influence of immunosuppressive drugs on hematological parameters comparing EVL versus CsA. RESULTS Twenty-eight patients were enrolled in the EVL and 12 in the CsA Groups. After OLT, hemoglobin (Hb), hematocrit (Hct), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), white blood cell (WBC), platelets (PLT), transferrin saturation (TSAT), iron, ferritin, and transferrin did not differ significantly between the 2 groups at any time point. Among the patients who reached 6-months of follow-up, 5 (41.7%) EVL and 4 (80%) CsA subjects were anemic (P=not significant [NS]). Only anemia in patients enrolled in Group EVL showed a trend toward the features of microcytic, hypochromic anemia. DISCUSSION Our results demonstrated that de novo anemia in OLT patients treated with EVL monotherapy showed the same incidence as in patients treated with CsA. Hb values remained similar during the entire follow-up. Moreover, overall myelosuppression in the EVL Group was not significantly different from patients in the CsA Group.
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Affiliation(s)
- M Masetti
- Liver and Multivisceral Transplant Center, University of Modena, Modena, Italy.
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Masetti M, Montalti R, Arpinati M, Di Benedetto F, Miller CM, Zagnoli A, De Ruvo N, Guerrini GP, Romano A, Rondelli D, Chirumbolo G, Rompianesi G, Pinna AD, Gerunda GE. High dose rabbit antithymocyte globulin induction in living related liver transplantation. Hepatogastroenterology 2007; 54:884-8. [PMID: 17591084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
BACKGROUND/AIMS Induction with rabbit antithymocyte globulin (RATG) has been reported to be effective in cadaveric liver transplantation. The aim of this study was to compare two immunosuppressive protocols in adult living-related liver transplantation (LRLT). METHODOLOGY From May 2001 through May 2003, 34 LRLT were performed. The first 17 patients (group 1) were treated with tacrolimus (TAC) and steroids. The next 17 patients (group 2) were treated with a steroid-sparing protocol using RATG. RESULTS The one-year patient and graft survival was respectively 76.5% and 64.7% for group 1 and 88.2 and 76.5% for group 2 (p = 0.037 and p = NS, respectively). Incidence of acute cellular rejection was 41.2% in group 1 compared to 47% in group 2 (p = NS). Mean daily TAC dose at 6 months was 6.5 +/- 1.1 mg/day in group 1 and 3.2 +/- 0.9 mg/day in group 2 (p < 0.001). In group 1, 41.1% experienced CMV infection compared to 11.7% in group 2 (p = NS). CONCLUSIONS These results suggest that this approach of RATG induction followed by postoperative, steroid-free, and low-dose TAC is safe and provides for adequate immunosuppression and similar outcome when compared to controls treated with standard TAC and steroid immunosuppression.
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Affiliation(s)
- Michele Masetti
- Liver and Multivisceral Transplant Center, University of Modena and Reggio Emilia, #71 via del Pozzo, 41100 Modena, Italy
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