Challenging Scenarios and Debated Indications for Laparoscopic Liver Resections for Hepatocellular Carcinoma.

Laparoscopic liver resections (LLRs) have been increasingly adopted for the treatment of hepatocellular carcinoma (HCC), with safe short- and long-term outcomes reported worldwide. Despite this, lesions in the posterosuperior segments, large and recurrent tumors, portal hypertension, and advanced cirrhosis currently represent challenging scenarios in which the safety and efficacy of the laparoscopic approach are still controversial. In this systematic review, we pooled the available evidence on the short-term outcomes of LLRs for HCC in challenging clinical scenarios. All randomized and non-randomized studies reporting LLRs for HCC in the above-mentioned settings were included. The literature search was run in the Scopus, WoS, and Pubmed databases. Case reports, reviews, meta-analyses, studies including fewer than 10 patients, non-English language studies, and studies analyzing histology other than HCC were excluded. From 566 articles, 36 studies dated between 2006 and 2022 fulfilled the selection criteria and were included in the analysis. A total of 1859 patients were included, of whom 156 had advanced cirrhosis, 194 had portal hypertension, 436 had large HCCs, 477 had lesions located in the posterosuperior segments, and 596 had recurrent HCCs. Overall, the conversion rate ranged between 4.6% and 15.5%. Mortality and morbidity ranged between 0.0% and 5.1%, and 18.6% and 34.6%, respectively. Full results according to subgroups are described in the study. Advanced cirrhosis and portal hypertension, large and recurrent tumors, and lesions located in the posterosuperior segments are challenging clinical scenarios that should be carefully approached by laparoscopy. Safe short-term outcomes can be achieved provided experienced surgeons and high-volume centers.

From "Cure" to "Care": The Role of the MultiDisciplinary Team on Colorectal Cancer Patients' Satisfaction and Oncological Outcomes.

Background: MultiDisciplinary Team (MDT) are held to undertake decisions regarding the whole aspect of oncological diseases. Over the years, they acquired a collaborative approach where clinical decisions are shared by all members. Different guidelines recommend the implementation of MDT, in order to improve the outcomes of these patients. Our aim is to evaluate how the implementation of MDT affects the patients' satisfaction and adherence to treatment. Methods: A survey was submitted to every patient affected by colorectal cancer treated by the MDT of Sant'Andrea Hospital (Rome, IT). The investigation period was January 2017-March 2020. Data from patients inside the MDT were compared with patients outside the MDT to evaluate a reduction in waiting times. Results: A total of 591 patients were collected. A total of 355 patients with colorectal neoplasia were included in our analysis. Cumulative overall survival was 79%. The average waiting time for computed tomography or colonoscopy was 14.9 days for patients in the MDT versus 24.5. A total of 201 patients were eligible for our satisfaction survey. An 89.5% of patients felt followed in their treatment. A 93.5% of patients expressed a high grade of satisfaction for the MDT design. Conclusion: Our study confirms the importance of a well-structured MDT. Dedicated slots shorten the waiting time, leading to better satisfaction and faster diagnosis. Patients' satisfaction should be considered as an index of good practice when it comes to oncological patients' treatment.

The learning curve of laparoscopic ablation of liver tumors: A technically demanding procedure requiring dedicated training.

BACKGROUND: Laparoscopic ablation (LA) of liver tumors is an increasingly performed procedure. However, LA is technically demanding, with inherent difficulties making LA more complex than percutaneous and open surgery ablations. This study aimed to characterize the learning curve (LC) of LAs. METHODS: All consecutive LAs of malignant liver tumors performed with curative intent by a single surgeon were identified from a prospective database. A risk-adjusted cumulative summative (RA-CUSUM) analysis was used for evaluating the LC of LAs. Incomplete ablation (IA) was the outcomes measure. Performance trends were analyzed using broken-line modeling. RESULTS: From June 2007 to February 2018, 241 lesions underwent LA during 151 procedures. RA-CUSUM analysis demonstrated an LC of 93 LAs (p < 0.001), with an IA rate decreasing from 12.9% to 4.7% (p = 0.027). Lesions in the posterosuperior segment and those in cirrhotic livers showed an LC of 34 and 45 tumor ablations, respectively (p=<0.001 each). Open ablations performed during the same period showed steady outcomes, indicating already acquired proficiency. CONCLUSION: Completion of a steep LC is needed to gain proficiency in LAs. Dedicated training should be warranted to novices to smooth the LC and decrease LA failures.

Laparoscopic Versus Open Thermal Ablation of Colorectal Liver Metastases: A Propensity Score-Based Analysis of Local Control of the Ablated Tumors.

BACKGROUND: Laparoscopic ablation (LA) of colorectal liver metastases (CRLMs) is frequently performed in combination with laparoscopic liver resection or as a stand-alone procedure. However, LA is technically demanding and whether the results are comparable with those of open ablation (OA) has not been determined to date. This study compared the effectiveness of LA and OA in achieving local tumor control of CRLMs. METHODS: Patients undergoing LA or OA of CRLMs at Ghent University Hospital between June 2007 and February 2018 were identified from a prospective database. Lesions treated by LA and OA were matched 1:1 using a propensity score based on lesions (liver segment, size, deepness, proximity to a vessel), patients, and procedural characteristics. Ablation sites were followed up with computed-tomography or magnetic resonance imaging to assess the completeness of the ablation and ablation-site recurrence (ASR). Analysis of ASR was performed with the Kaplan-Meier method and Cox regression. RESULTS: In this study, 163 patients underwent the surgical ablation (78 LA, 85 OA) of 333 CRLMs (143 LA, 190 OA). After matching, 220 lesions (110 LA, 110 OA) were analyzed. Ablation was complete in 93.7% (LA) and 97.3% (OA) of the sites (p = 0.195). No difference in ASR was observed (p = 0.351), with a cumulative risk of ASR at 12 months of 9.1% (LA) and 8.2% (OA). After multivariable analysis, ASR was confirmed to be independent of the surgical approach. CONCLUSION: The findings showed that LA and OA achieve a comparable local control of CRLMs. This result further supports the adoption of a laparoscopic approach for the treatment of CRLMs.

A positive proximal resection margin is associated with anastomotic complications following primary ileocaecal resection for Crohn's disease.

PURPOSES: Bowel resection in patients with Crohn's disease (CD) has a high reported rate of postoperative complications and surgical recurrence. A macroscopically normal resection margin is recommended in CD surgery as wider margins do not translate in reduced recurrence rates. The aim of this study was to evaluate the association between resection margin status and anastomotic complications following ileocaecal resection for primary CD. METHODS: All patients treated with ileocaecal resection for primary CD from 2010 to 2018 were included in this retrospective observational study. Emergency operations and recurrent CD were excluded. Patients in whom an anastomosis was not fashioned at the time of the surgery were also excluded. Histopathology data collected included macroscopic description, presence of macroscopic and microscopic involvement of the proximal and distal resection margins. The primary outcome was the rate of positive resection margin in patients who developed anastomotic complications (anastomotic leaks and intra-abdominal collections), and the secondary outcomes were overall complications rate, length of hospital stay, reoperations and rehospitalisation within 30 days. RESULTS: A total of 104 patients were included. The proximal resection margin was microscopically involved in 19 patients (18.2%). Ten patients (9.6%) developed intra-abdominal anastomotic related complications, with 5 patients out of 10 (50%) in the group of postoperative anastomotic complications having a positive microscopic proximal margin at histology, compared to 14 patients (14.9%) in the group that did not develop anastomotic complications (p < 0.0001). CONCLUSIONS: Microscopic involvement of the proximal resection margin is more frequent in patients who develop postoperative anastomotic complications following elective ileocaecal resection for primary CD.