COVID-19 Epidemic in the Middle Province of Northern Italy: Impact, Logistics, and Strategy in the First Line Hospital.

The novel coronavirus (COVID-19) began in China in early December 2019 and rapidly has spread to many countries around the globe, with the number of confirmed cases increasing every day. An epidemic has been recorded since February 20 in a middle province in Northern Italy (Lodi province, in the low Po Valley). The first line hospital had to redesign its logistical and departmental structure to respond to the influx of COVID-19-positive patients who needed hospitalization. Logistical and structural strategies were guided by the crisis unit, managing in 8 days from the beginning of the epidemic to prepare the hospital to be ready to welcome more than 200 COVID-19-positive patients with different ventilatory requirements, keeping clean emergency access lines, and restoring surgical interventions and deferred urgent, routine activity.

Safety and feasibility of laparoscopic liver resection with associated lymphadenectomy for intrahepatic cholangiocarcinoma: a propensity score-based case-matched analysis from a single institution.

BACKGROUND: Intrahepatic cholangiocarcinoma (ICC) is still a relatively uncommon indication for laparoscopic surgery because of technical challenges related to the frequent need for major hepatectomies and the necessity to perform formal regional lymphadenectomy. The aim of the present case-matched study was to compare laparoscopic and open resections for ICC. METHODS: In a case-matched retrospective analysis, 20 consecutive patients who had undergone laparoscopic resection for ICC (LPS group) were compared with 60 of 83 patients who had undergone open surgery (open group) in the same institution. The groups were matched in a ratio of 1:3 using propensity scores based on covariates representing relevant patient characteristics and severity of disease. The main endpoints were short- and long-term outcomes and impact and adequacy of laparoscopic lymphadenectomy. RESULTS: The groups were well matched in terms of patient and disease characteristics. The laparoscopic approach resulted in less blood loss (200 vs. 350 mL, p = 0.040) despite less extensive use of the Pringle maneuver. There was no difference in perioperative morbidity and mortality rates; however, the laparoscopic approach was associated with faster functional recovery (median 3 vs. 4 days, p = 0.050). After a mean follow-up of 39 months, disease-free and overall survivals were 33 and 51 months, respectively, for the LPS and 36 and 63, respectively, for the open group (p ns). The number of harvested nodes was comparable between groups. CONCLUSIONS: Compared with open surgery, laparoscopic resection of ICC is feasible and safe, providing short-term benefits without negatively affecting oncologic adequacy in terms of rate of R0 resections, depth of margins, and long-term overall and disease-free survivals. Laparoscopic regional lymphadenectomy is technically possible but should be the object of future focused studies.

Defining indications to ALPPS procedure: technical aspects and open issues.

The limit to surgical treatment of patients with hepatic tumors is represented by the proportion of residual hepatic parenchyma at the end of surgery (FLR, future liver remnant) that provides an estimation of the risk of postoperative liver failure. Recently, a new two-stage technique has been developed with the acronym (ALPPS) associating liver partitioning and portal vein ligation for staged hepatectomy with the aim of obtaining a more rapid and effective increase in FLR, even though indications are not clear yet. Between January and December 2012, eight patients were candidates to ALPPS at the Hepatobiliary Surgery Unit of San Raffaele Hospital, Milan. The first three patients (Series 1) underwent right trisectionectomy and were affected by tumors infiltrating biliary confluence, while the others (Series 2) were candidates to right hepatectomy for colorectal liver metastases. Two patients were then excluded from Series 2 because intraoperative finding of irresectable disease. Intra- and postoperative outcome was evaluated with the aim of defining indications to ALPPS. All patients reached an adequate FLR after a median of 7.5 days from the first procedure (rate of program completion 100 %). In Series 1 two patients developed complications related to bile leakage from the raw surface of the liver to be resected and septic events secondary to ischemic necrosis of the liver segment IV. One patient died following multi-organ failure secondary to sepsis. In Series 2 postoperative course was uneventful in all the patients, and in particular no patient showed disease progression between the two procedures or signs of postoperative liver failure. ALPPS approach was initially considered suitable for patients affected by Klatskin tumors who require, despite a small tumor volume, extended hepatectomies associated with surgery of the biliary tract: the analysis of this first series of patients has led to a re-evaluation of the indication to this strategy, as a consequence of encountered criticisms. Actually only a subset of patients affected by colorectal liver metastases are candidates to ALPPS.