Rescue from complications after pancreaticoduodenectomies at a low-volume Caribbean center: Value of tailored peri-pancreatectomy protocols.

BACKGROUND: Pancreaticoduodenectomy (PD) is a technically complex operation, with a relatively high risk for complications. The ability to rescue patients from post-PD complications is as a recognized quality measure. Tailored protocols were instituted at our low volume facility in the year 2013. AIM: To document the rate of rescue from post-PD complications with tailored protocols in place as a measure of quality. METHODS: A retrospective audit was performed to collect data from patients who experienced major post-PD complications at a low volume pancreatic surgery unit in Trinidad and Tobago between January 1, 2013 and June 30, 2023. Standardized definitions from the International Study Group of Pancreatic Surgery were used to define post-PD complications, and the modified Clavien-Dindo classification was used to classify post-PD complications. RESULTS: Over the study period, 113 patients at a mean age of 57.5 years (standard deviation [SD] ± 9.23; range: 30-90; median: 56) underwent PDs at this facility. Major complications were recorded in 33 (29.2%) patients at a mean age of 53.8 years (SD: ± 7.9). Twenty-nine (87.9%) patients who experienced major morbidity were salvaged after aggressive treatment of their complication. Four (3.5%) died from bleeding pseudoaneurysm (1), septic shock secondary to a bile leak (1), anastomotic leak (1), and myocardial infarction (1). There was a significantly greater salvage rate in patients with American Society of Anesthesiologists scores ≤ 2 (93.3% vs 25%; P = 0.0024). CONCLUSION: This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring PD. Despite low volumes at our facility, we demonstrated that 87.9% of patients were rescued from major complications. We attributed this to several factors including development of rescue protocols, the competence of the pancreatic surgery teams and continuous, and adaptive learning by the entire institution, culminating in the development of tailored peri-pancreatectomy protocols.

Whipple's pancreaticoduodenectomy at a resource-poor, low-volume center in Trinidad and Tobago.

BACKGROUND: Many authorities advocate for Whipple's procedures to be performed in high-volume centers, but many patients in poor developing nations cannot access these centers. We sought to determine whether clinical outcomes were acceptable when Whipple's procedures were performed in a low-volume, resource-poor setting in the West Indies. AIM: To study outcomes of Whipple's procedures in a pancreatic unit in the West Indies over an eight-year period from June 1, 2013 to June 30, 2021. METHODS: This was a retrospective study of all patients undergoing Whipple's procedures in a pancreatic unit in the West Indies over an eight-year period from June 1, 2013 to June 30, 2021. RESULTS: This center performed an average of 11.25 procedures per annum. There were 72 patients in the final study population at a mean age of 60.2 years, with 52.7% having American Society of Anesthesiologists scores ≥ III and 54.1% with Eastern Cooperative Oncology Group scores ≥ 2. Open Whipple's procedures were performed in 70 patients and laparoscopic assisted procedures in 2. Portal vein resection/reconstruction was performed in 19 (26.4%) patients. In patients undergoing open procedures there was 367 ± 54.1 min mean operating time, 1394 ± 656.8 mL mean blood loss, 5.24 ± 7.22 d mean intensive care unit stay and 15.1 ± 9.53 d hospitalization. Six (8.3%) patients experienced minor morbidity, 10 (14%) major morbidity and there were 4 (5.5%) deaths. CONCLUSION: This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring Whipple's procedures. Low volume centers in resource poor nations can achieve good short-term outcomes. This is largely due to the process of continuous, adaptive learning by the entire hospital.

Whipple's operation with a modified centralization concept: A model in low-volume Caribbean centers.

Conventional data suggest that complex operations, such as a pancreaticoduodenectomy (PD), should be limited to high volume centers. However, this is not practical in small, resource-poor countries in the Caribbean. In these settings, patients have no option but to have their PDs performed locally at low volumes, occasionally by general surgeons. In this paper, we review the evolution of the concept of the high-volume center and discuss the feasibility of applying this concept to low and middle-income nations. Specifically, we discuss a modification of this concept that may be considered when incorporating PD into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating studies published on outcomes after PD in high volume centers. The data in the Caribbean is then examined and we discuss the incorporation of this operation into resource-poor hospitals with modifications of the centralization concept. In the authors' opinions, most patients who require PD in the Caribbean do not have realistic opportunities to have surgery in high-volume centers in developed countries. In these settings, their only options are to have their operations in the resource-poor, low-volume settings in the Caribbean. However, post-operative outcomes may be improved, despite low-volumes, if a modified centralization concept is encouraged.

Utility of KI-67 as a prognostic biomarker in pulmonary neuroendocrine neoplasms: a systematic review and meta-analysis.

OBJECTIVES: Ki-67, a marker of cellular proliferation, is associated with prognosis across a wide range of tumours, including gastroenteropancreatic neuroendocrine neoplasms (NENs), lymphoma, urothelial tumours and breast carcinomas. Its omission from the classification system of pulmonary NENs is controversial. This systematic review sought to assess whether Ki-67 is a prognostic biomarker in lung NENs and, if feasible, proceed to a meta-analysis. RESEARCH DESIGN AND METHODS: Medline (Ovid), Embase, Scopus and the Cochrane library were searched for studies published prior to 28 February 2019 and investigating the role of Ki-67 in lung NENs. Eligible studies were those that included more than 20 patients and provided details of survival outcomes, namely, HRs with CIs according to Ki-67 percentage. Studies not available as a full text or without an English manuscript were excluded. This study was prospectively registered with PROSPERO. RESULTS: Of 11 814 records identified, seven studies met the inclusion criteria. These retrospective studies provided data for 1268 patients (693 TC, 281 AC, 94 large cell neuroendocrine carcinomas and 190 small cell lung carcinomas) and a meta-analysis was carried out to estimate a pooled effect. Random effects analyses demonstrated an association between a high Ki-67 index and poorer overall survival (HR of 2.02, 95% CI 1.16 to 3.52) and recurrence-free survival (HR 1.42; 95% CI 1.01 to 2.00). CONCLUSION: This meta-analysis provides evidence that high Ki-67 labelling indices are associated with poor clinical outcomes for patients diagnosed with pulmonary NENs. This study is subject to inherent limitations, but it does provide valuable insights regarding the use of the biomarker Ki-67, in a rare tumour. PROSPERO REGISTRATION NUMBER: CRD42018093389.

Analysis of Immune Landscape in Pancreatic and Ileal Neuroendocrine Tumours Demonstrates an Immune Cold Tumour Microenvironment.

INTRODUCTION: Neuroendocrine tumours (NETs) are rare tumours with an increasing incidence. While low- and intermediate-grade pancreatic NET (PanNET) and small intestinal NET (siNET) are slow growing, they have a relatively high rate of metastasizing to the liver, leading to substantially worse outcomes. In many solid tumours, the outcome is determined by the quality of the antitumour immune response. However, the quality and significance of antitumour responses in NETs are incompletely understood. This study provides clinico-pathological analyses of the tumour immune microenvironment in PanNET and siNETs. METHODS: Formalin-fixed paraffin-embedded tissue from consecutive resected PanNETs (61) and siNETs (131) was used to construct tissue microarrays (TMAs); 1-mm cores were taken from the tumour centre, stroma, tumour edge, and adjacent healthy tissue. TMAs were stained with antibodies against CD8, CD4, CD68, FoxP3, CD20, and NCR1. T-cell counts were compared with counts from lung cancers. RESULTS: For PanNET, median counts were CD8+ 35.4 cells/mm2, CD4+ 7.6 cells/mm2, and CD68+ macrophages 117.7 cells/mm2. For siNET, there were CD8+ 39.2 cells/mm2, CD4+ 24.1 cells/mm2, and CD68+ 139.2 cells/mm2. The CD8+ cell density in the tumour and liver metastases were significantly lower than in the adjacent normal tissues, without evidence of a cell-rich area at the tumour edge that might have suggested immune exclusion. T-cell counts in lung cancer were significantly higher than those in PanNET and siNETs: CD8+ 541 cells/mm2 and CD4+ 861 cells/mm2 (p ≤ 0.0001). CONCLUSION: PanNETs and siNETs are immune cold with no evidence of T cell exclusion; the low density of immune infiltrates indicates poor antitumour immune responses.

Review of minimally invasive pancreas surgery and opinion on its incorporation into low volume and resource poor centres.

Pancreatic surgery has been one of the last areas for the application of minimally invasive surgery (MIS) because there are many factors that make laparoscopic pancreas resections difficult. The concept of service centralization has also limited expertise to a small cadre of high-volume centres in resource rich countries. However, this is not the environment that many surgeons in developing countries work in. These patients often do not have the opportunity to travel to high volume centres for care. Therefore, we sought to review the existing data on MIS for the pancreas and to discuss. In this paper, we review the evolution of MIS on the pancreas and discuss the incorporation of this service into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating all studies published on laparoscopic and robotic surgery of the pancreas. The data in the Caribbean is examined and we discuss tips for incorporating this operation into resource poor hospital practice. Low pancreatic case volume in the Caribbean, and financial barriers to MIS in general, laparoscopic distal pancreatectomy, enucleation and cystogastrostomy are feasible operations to integrate in to a resource-limited healthcare environment. This is because they can be performed with minimal to no consumables and require an intermediate MIS skillset to complement an open pancreatic surgeon's peri-operative experience.

Anatomic variations of the intra-hepatic biliary tree in the Caribbean: A systematic review.

BACKGROUND: In the classic descriptions of the human liver, the common hepatic duct forms at the confluence of left and right hepatic ducts. Many authors have documented variations in the intra-hepatic ductal system, but to the best of our knowledge there has been no report on bile duct variations in Caribbean populations. AIM: To evaluate the variations in bile duct anatomy using magnetic resonance cholangiography (MRC) in unselected patients at a major hepatobiliary referral centre in the Eastern Caribbean. Knowledge of the intra-hepatic biliary anatomy is important to optimize service delivery for any physician treating liver and biliary disorders. METHODS: This study was carried out at a tertiary referral hospital for hepatobiliary diseases in the Eastern Caribbean. We retrospectively evaluated magnetic resonance cholangiograms in 152 consecutive patients at this facility over a two-year period from April 1, 2017 to March 31, 2019. Two consultant radiologists experienced in MRC interpretation reviewed all scans and described biliary anatomy according to the Huang's classification. A systematic review of published studies was performed and relevant data were extracted in order to calculate the global prevalence of each biliary variant. The variants in our population were compared to the global population. RESULTS: There were 152 MRCs evaluated in this study in 86 males and 66 females. There were 109 (71.7%) persons with "classic" biliary anatomy (type A1) and variants were present in 43 (28.3%) persons. There was no statistical relationship between the presence of anatomic variants and gender or ethnicity. We encountered the following variants: 29 (19.1%) type A2, 7 (4.6%) type A3, 6 (3.95%) type A4, 0 type A5 and a single variant (quadrification) that did not fit the classification system. Compared to the global prevalence, our population had a significantly greater occurrence of A1 anatomy (71.7% vs 62.6%; P = 0.0227) and A2 trifurcations (19.1% vs 11.5%; P = 0.0069), but a significantly lower incidence of A3 variants (4.61% vs 11.5%; P = 0.0047). CONCLUSION: There are significant differences in intra-hepatic biliary anatomy in this unselected Eastern Caribbean population compared to global statistics. Specifically, persons of Caribbean descent have a greater incidence of Huang A2 trifurcations and a lower incidence of Huang A3 variants.

Surgical relevance of anatomic variations of the right hepatic vein.

BACKGROUND: Variations in the anatomy of hepatic veins are of interest to transplant surgeons, interventional radiologists, and other medical practitioners who treat liver diseases. The drainage patterns of the right hepatic veins (RHVs) are particularly relevant to transplantation services. AIM: The aim was to identify variations of the patterns of venous drainage from the right side of the liver. To the best of our knowledge, there have been no reports on RHV variations in in a Caribbean population. METHODS: Two radiologists independently reviewed 230 contrast-enhanced computed tomography scans performed in 1 year at a hepatobiliary referral center. Venous outflow patterns were observed and RHV variants were described as: (1) Tributaries of the RHV; (2) Variations at the hepatocaval junction (HCJ); and (3) Accessory RHVs. RESULTS: A total of 118 scans met the inclusion criteria. Only 39% of the scans found conventional anatomy of the main hepatic veins. Accessory RHVs were present 49.2% and included a well-defined inferior RHV draining segment VI (45%) and a middle RHV (4%). At the HCJ, 83 of the 118 (70.3%) had a superior RHV that received no tributaries within 1 cm of the junction (Nakamura and Tsuzuki type I). In 35 individuals (29.7%) there was a short superior RHV with at least one variant tributary. According to the Nakamura and Tsuzuki classification, there were 24 type II variants (20.3%), six type III variants (5.1%) and, five type IV variants (4.2%). CONCLUSION: There was significant variation in RHV patterns in this population, each with important relevance to liver surgery. Interventional radiologists and hepatobiliary surgeons practicing in the Caribbean must be cognizant of these differences in order to minimize morbidity during invasive procedures.

Human liver umbilical fissure variants: pons hepatis (ligamentum teres tunnel).

PURPOSE: In the classical description of normal liver anatomy, the umbilical fissure is a long, narrow groove that receives the ligamentum teres hepatis. The pons hepatis is an anatomic variant, where the umbilical fissure is converted into a tunnel by an overlying bridge of liver parenchyma. We carried out a study to evaluate the existing variations of the umbilical fissure in a Caribbean population. METHODS: We observed all consecutive autopsies performed at a facility in Jamaica and selected cadavers with a pons hepatis for detailed study. A pons hepatis was considered present when the umbilical fissure was covered by hepatic parenchyma. We recognized two variants: an open-type (incomplete) pons hepatis in which the umbilical fissure was incompletely covered by parenchyma ≤ 2 cm in length and a closed type (complete) pons hepatis in which the umbilical fissure was covered by a parenchymal bridge > 2 cm and thus converted into a tunnel. We measured the length (distance from transverse fissure to anterior margin of the parenchymatous bridge), width (extension across the umbilical fissure in a coronal plane) and thickness (distance from the visceral surface to the hepatic surface measured at the mid-point of the parenchymal bridge in a sagittal plane) of each pons hepatis. A systematic literature review was also performed to retrieve data from relevant studies. The raw data from these retrieved studies was used to calculate the global point prevalence of pons hepatis and compared the prevalence in our population. RESULTS: Of 66 autopsies observed, a pons hepatis was present in 27 (40.9%) cadavers. There were 15 complete variants, with a mean length of 34.66 mm, mean width of 16.98 mm and mean thickness of 10.98 mm. There were 12 incomplete variants, with a mean length of 17.02 mm, width of 17.03 mm and thickness of 9.56 mm. The global point prevalence of the pons hepatis (190/5515) was calculated to be or 3.45% of the global population. CONCLUSIONS: We have proposed a classification of the pons hepatis that is reproducible and clinically relevant. This allowed us to identify a high prevalence of pons hepatis (41%) in this Afro-Caribbean population that is significantly greater than the global prevalence (3.45%; P < 0.0001).

Hepatic surface grooves in Trinidad and Tobago.

PURPOSE: Hepatic surface grooves (HSGs) are prominent depressions on the antero-superior surface of the liver. We sought to document the prevalence of HSGs in an Eastern Caribbean population. METHODS: We observed all consecutive autopsies performed at a facility in Trinidad and Tobago and recorded the presence, number, location, width, length and depth of any HSG identified. Each liver was then sectioned to document intra-parenchymal abnormalities. RESULTS: Sixty Autopsies were observed. There were HSGs in 9 (15%) cadavers (5 females and 4 males), at an average age of 66 years (range 48-83, Median 64, SD ± 10.4). The HSGs were located on the diaphragmatic surface of the right hemi-liver in 8 (89%) cadavers, left medial section in 4 (44%), left lateral section in 3 (33%) and coursing along Cantlie's plane in 3 (33%) cadavers. Eight (89%) cadavers with HSGs had other associated anomalies: accessory inferior grooves (5), parenchymal nutmeg changes (5), abnormal caudate morphology (4), hyperplastic left hemi-liver (3), lingular process (2), bi-lobar gallbladder (1) and/or abnormal ligamentous attachments (1). CONCLUSIONS: Approximately 15% of unselected Afro-Caribbean persons in this Eastern Caribbean population have HSGs. Every attempt should be made to identify HSGs on pre-operative imaging because they can alert the hepatobiliary surgeon to: (1) associated anatomic anomalies in 89% of cases, (2) associated hepatic congestion in 56% of persons, (3) increased risk of bleeding during liver resections and (4) increased technical complexity of liver resections. The association between HSGs, cardiovascular complications, hepatic congestion and nutmeg liver prompted us to propose a new aetiologic mechanism for HSG formation, involving localized hyperplasia at growth zones due to upregulation of beta-catenin levels.

Laparoscopic Liver Resection by Distance Mentoring - Trinidad to Barbados: A Report.

Laparoscopic liver resections require advanced laparoscopic skill sets. In the Caribbean, a unique situation exists where centers of excellence for liver resections exist, but surgeons who are trained in advanced laparoscopic surgery are not available throughout the region. Therefore, many patients who are candidates for liver resection in the Caribbean do not have the opportunity to receive laparoscopic operations.  We report a case of distance mentoring using readily available, inexpensive equipment to complete a laparoscopic liver resection, mentored by an expert hepatobiliary surgeon. It may be considered, in special cases, as a way to increase the availability of laparoscopic operations. We acknowledge that there are many limitations to the use of this technology and we discuss the pros and cons of distance mentoring for this purpose.

Escalation-related decision making in acute deterioration: a retrospective case note review.

AIM: To describe how decision making inter-relates with the sequence of events in individuals who die during admission and identify situations where formal treatment escalation plans (TEPs) may have utility. DESIGN AND METHODS: A retrospective case note review using stratified sampling. Two data analysis methods were applied concurrently: directed content analysis and care management process mapping via annotated timelines for each case. Analysis was followed by expert clinician review (n=7), contributing to data interpretation. SAMPLE: 45 cases, age range 38-96 years, 23 females and 22 males. Length of admission ranged from <24 hours to 97 days. RESULTS: Process mapping led to a typology of care management, encompassing four trajectories: early de-escalation due to catastrophic event; treatment with curative intent throughout; treatment with curative intent until significant point; and early treatment limits set. Directed content analysis revealed a number of contextual issues influencing decision making. Three categories were identified: multiple clinician involvement, family involvement and lack of planning clarity; all framed by clinical complexity and uncertainty. CONCLUSIONS: The review highlighted the complex care management and related decision-making processes for individuals who face acute deterioration. These processes involved multiple clinicians, from numerous specialities, often within hierarchical teams. The review identified the need for visible and clear management plans, in spite of the frame of clinical uncertainty. Formal TEPs can be used to convey such a set of plans. Opportunities need to be created for patients and their families to request TEPs, in consultation with the clinicians who know them best, outside of the traumatic circumstances of acute deterioration.

Surgeons' assessment versus risk models for predicting complications of hepato-pancreato-biliary surgery (HPB-RISC): a multicenter prospective cohort study.

BACKGROUND: Several studies advise the use of risk models when counseling patients for hepato-pancreato-biliary (HPB) surgery, but studies comparing these models to the surgeons' assessment are lacking. The aim of this study was to assess whether risk prediction models outperform surgeons' assessment for the risk of complications in HPB surgery. METHODS: This prospective study included adult patients scheduled for HPB surgery in three centers in the UK and the Netherlands. Primary outcome was the rate of postoperative major complications. Surgeons assessed the risk prior to surgery while blinded for the formal risk scores. Risk prediction models were retrieved via a systematic review and risk scores were calculated. For each model, discrimination and calibration were evaluated. RESULTS: Overall, 349 patients were included. The rate of major complications was 27% and in-hospital mortality 3%. Surgeons' assessment resulted in an AUC of 0.64; 0.71 for liver and 0.56 for pancreas surgery (P = 0.020). The AUCs for nine existing risk prediction models ranged between 0.57 and 0.73 for liver surgery and between 0.51 and 0.57 for pancreas surgery. CONCLUSION: In HPB surgery, existing risk prediction models do not outperform surgeons' assessment. Surgeons' assessment outperforms most risk prediction models for liver surgery although both have a poor predictive performance for pancreas surgery. REGISTRATION INFORMATION: REC reference number (13/SC/0135); IRAS ID (119370). TRIALREGISTER.NL: NTR4649.

Clinically Significant Differences in Ki-67 Proliferation Index Between Primary and Metastases in Resected Pancreatic Neuroendocrine Tumors.

OBJECTIVE: Pancreatic neuroendocrine tumors (NETs) (pNETs) have a varied prognosis according to their grade. The European Neuroendocrine Tumor Society grading system uses assessment of the proliferation index via Ki-67 immunohistochemistry to aid prognosis. There is evidence that the proliferation index can vary significantly within a single tumor, but it is not fully understood to what extent heterogeneity occurs between the primary and metastatic sites and how this may affect the grade. The aim of this study is to determine whether the grade assigned to a pNET varies depending on which site is selected for Ki-67 immunolabeling. METHODS: Patients were selected from our institution's NET database. Patients were included if they had a confirmed pNETs, had multiple resection specimens, and had consented to research being performed on their specimens. Ki-67 immunohistochemistry was performed on all resected specimens meeting the inclusion criteria. RESULTS: Pancreatic neuroendocrine tumors specimens resected from 16 patients were analyzed. There was no trend to higher Ki-67 in metastatic than primary disease. Ki-67 was on average 3% higher in liver metastases than lymph node metastases (P < 0.001). CONCLUSIONS: The grade of pNETs varies according to the tumor selected for Ki-67 immunolabeling. Useful information can be gained by performing Ki-67 PI on liver metastases.

Outcome and Learning Curve in 159 Consecutive Patients Undergoing Total Laparoscopic Hemihepatectomy.

Importance: Widespread implementation of laparoscopic hemihepatectomy is currently limited by its technical difficulty, paucity of training opportunities, and perceived long and harmful learning curve. Studies confirming the possibility of a short and safe learning curve for laparoscopic hemihepatectomy could potentially benefit the further implementation of the technique. Objective: To evaluate the extent and safety of the learning curve for laparoscopic hemihepatectomy. Design, Setting, and Participants: A prospectively collected single-center database containing all laparoscopic liver resections performed in our unit at the University Hospital Southampton National Health Service Foundation Trust between August 2003 and March 2015 was retrospectively reviewed; analyses were performed in December 2015. The study included 159 patients in whom a total laparoscopic right or left hemihepatectomy procedure was started (intention-to-treat analysis), including laparoscopic extended hemihepatectomies and hemihepatectomies with additional wedge resections, at a tertiary referral center specialized in laparoscopic hepato-pancreato-biliary surgery. Main Outcomes and Measures: Primary end points were clinically relevant complications (Clavien-Dindo grade ≥III). The presence of a learning curve effect was assessed with a risk-adjusted cumulative sum analysis. Results: Of a total of 531 consecutive laparoscopic liver resections, 159 patients underwent total laparoscopic hemihepatectomy (105 right and 54 left). In a cohort with 67 men (42%), median age of 64 years (interquartile range [IQR], 51-73 years), and 110 resections (69%) for malignant lesions, the overall median operation time was 330 minutes (IQR, 270-391 minutes) and the median blood loss was 500 mL (IQR, 250-925 mL). Conversion to an open procedure occurred in 17 patients (11%). Clinically relevant complications occurred in 17 patients (11%), with 1% mortality (death within 90 days of surgery, n = 2). Comparison of outcomes over time showed a nonsignificant decrease in conversions (right: 14 [13%] and left: 3 [6%]), blood loss (right: 550 mL [IQR, 350-1150 mL] and left: 300 mL [IQR, 200-638 mL]), complications (right: 15 [14%] and left: 4 [7%]), and hospital stay (right: 5 days [IQR, 4-7 days] and left: 4 days [IQR, 3-5 days]). Risk-adjusted cumulative sum analysis demonstrated a learning curve of 55 laparoscopic hemihepatectomies for conversions. Conclusions and Relevance: Total laparoscopic hemihepatectomy is a feasible and safe procedure with an acceptable learning curve for conversions. Focus should now shift to providing adequate training opportunities for centers interested in implementing this technique.

Oncological outcomes of laparoscopic surgery of liver metastases: a single-centre experience.

In the era of multimodal management of liver metastases, surgical resection remains the only curative option, with open approach still being referred to as the standard of care. Currently, the feasibility and benefits of the laparoscopic approach for liver resection have been largely demonstrated. However, its oncologic adequacy remains to be confirmed. The aim of this study is to report the oncological results of laparoscopic liver resection for metastatic disease in a single-centre experience. A single-centre database of 413 laparoscopic liver resections was reviewed and procedures for liver metastases were selected. The assessment of oncologic outcomes included analysis of minimal tumour-free margin, R1 resection rate and 3-year survival. The feasibility and safety of the procedures were also evaluated through analysis of perioperative outcomes. The study comprised 209 patients (294 procedures). Colorectal liver metastases were the commonest indication (67.9%). Fourteen patients had conversion (6.7%) and oncological concern was the commonest reason for conversion (42.8%). Median tumour-free margin was 10 mm and complete radical resections were achieved in 211 of 218 curative-intent procedures (96.7%). For patients affected by colorectal liver metastases, 1- and 3-year OS resulted 85.9 and 66.7%. For patients affected by neuroendocrine liver metastases, 1- and 3-year OS resulted 93 and 77.8%. Among the patients with metastases from other primaries, 1- and 3-year OS were 83.3 and 70.5%. The laparoscopic approach is a safe and valid option in the treatment of patients with metastatic liver disease undergoing curative resection. It does offer significant perioperative benefits without compromise of oncologic outcomes.

Laparoscopic Parenchymal-Sparing Resections for Nonperipheral Liver Lesions, the Diamond Technique: Technical Aspects, Clinical Outcomes, and Oncologic Efficiency.

BACKGROUND: Surgical management of liver lesions has moved toward "parenchymal-sparing" strategies. Although open parenchymal-sparing liver resections are supported by encouraging results, the applicability of the laparoscopic approach for nonperipheral tumors is still questionable. Our aim was to assess the feasibility, safety, and oncologic adequacy of laparoscopic parenchymal-sparing liver resection for nonperipheral lesions with a description of the technique adopted in this setting. STUDY DESIGN: A prospectively collected single-center database of 517 laparoscopic liver resections was reviewed. Laparoscopic nonperipheral parenchymal-sparing liver resections (LapPSLRs), that is, entirely intraparenchymal limited resections performed on nonperipheral lesions, were selected. Intra- and perioperative outcomes were analyzed along with 3-year actuarial survival for patients with colorectal liver metastases. RESULTS: The group comprised 49 LapPSLRs. Colorectal liver metastases were the most frequent diagnosis (n = 24 patients). Lesions were located in segments 8, 7, 4a, and 3 in 51%, 8.2%, 36.7%, and 4.1% of cases, respectively. Conversion occurred in 4 patients (8%). Intra- and postoperative short-term outcomes were calculated for the 24 isolated LapPSLR (not associated with any concurrent liver resection). Median operative time and blood loss were 215 minutes and 225 mL, respectively. Pringle maneuver was used in 75% of cases. Postoperative 90-day mortality was nil and morbidity rate was 12.5%. Median postoperative stay was 3 days. Median tumor-free margin was 4 mm and 100% R0 rate was achieved for all LapPSLRs with curative intent. Three-year overall, recurrence-free, and disease-free survival rates were 100%, 65.2%, and 69.6%, respectively. CONCLUSIONS: Laparoscopic parenchymal-sparing liver resections for nonperipheral liver lesions are feasible and can be performed safely without compromising perioperative and oncological outcomes.

The impact of laparoscopic versus open colorectal cancer surgery on subsequent laparoscopic resection of liver metastases: A multicenter study.

BACKGROUND: Laparoscopic liver surgery is expanding. Most laparoscopic liver resections for colorectal carcinoma metastases are performed subsequent to the resection of the colorectal primary, raising concerns about the feasibility and safety of advanced laparoscopic liver surgery in the context of an abdomen with possible postoperative adhesions. The aim was to compare the outcome of laparoscopic hepatectomy for colorectal metastases after open versus laparoscopic colorectal surgery. METHODS: This observational, multicenter study reviewed 394 patients undergoing laparoscopic minor and major liver resection for colorectal carcinoma metastases. Main outcome measures were intraoperative unfavorable incidents and short-term results in patients who had previous open versus laparoscopic colorectal cancer surgery. RESULTS: Three hundred six patients (78%) had prior open and 88 (22%) had prior laparoscopic colorectal resection. Laparoscopic major hepatectomies were undertaken in 63 (16%). Intraoperative unfavorable incidents during laparoscopic liver surgery were significantly higher among patients who had prior open colorectal surgery (26%) compared with the laparoscopic group (14%; P = .017). Positive resection margins and postoperative complications were not associated with the approach adopted for the resection of the primary cancer. On multivariate logistic regression analysis, intraoperative unfavorable incidents were associated significantly only with prior open colorectal surgery (odds ratio, 2.8; P = .006) and laparoscopic major hepatectomy (odds ratio, 2.4; P = .009). CONCLUSION: Laparoscopic minor hepatectomy can be performed safely in patients who have undergone previous open colorectal surgery. Laparoscopic major hepatectomy after open colorectal surgery may be challenging. Careful risk assessment in the decision-making process is required not to compromise patient safety and to guarantee the expected benefits from the minimally invasive approach.

Laparoscopic liver resection for lesions adjacent to major vasculature: feasibility, safety and oncological efficiency.

BACKGROUND AND OBJECTIVES: Laparoscopic liver resection for lesions adjacent to major vasculature can be challenging, and many would consider it a contraindication. Recently, however, laparoscopic liver surgeons have been pushing boundaries and approached some of these lesions laparoscopically. We assessed feasibility, safety and oncological efficiency of this laparoscopic approach for these lesions. METHODS: This is a monocenter study (2003-2013) describing technique and outcomes of laparoscopic liver resection for lesions adjacent to major vasculature: <2 cm from the portal vein (main trunk and first division), hepatic arteries or inferior vena cava. RESULTS: Thirty-seven patients underwent laparoscopic liver resection (LLR) for a lesion adjacent to major vasculature. Twenty-four (65%) resections were for malignant disease and 92% R0 resections. Conversion occurred in three patients (8%). Mean operative time was 313 min (standard deviation (SD) ± 101) and intraoperative blood loss 400 ml (IQR 213-700). Clavien-Dindo complications > II occurred in two cases (5%), with no mortality. Lesions at <1 cm were larger (7.2 cm (2.7-14) vs. 3 cm (2.5-5), p = 0.03) and operation time was longer (344 ± 94 vs. 262 ± 92 min, p = 0.01) than lesions at 1-2 cm from major vasculature. CONCLUSIONS: Lesions <2 cm from major hepatic vasculature do not represent an absolute contraindication for LLR when performed by experienced laparoscopic liver surgeons in selected patients.