Spontaneous idiopathic liver hemorrhage: a systematic review of a rare entity.

BACKGROUND: Spontaneous idiopathic liver hemorrhage (SILH) is a rare life-threatening condition occurring without a clear and specific etiology. A systematic review was performed to provide guidelines for the perioperative management of patients affected by SILH. A case report was also included. METHODS: A systematic search of the last 24-year literature was conducted and the manuscript was structured following point-by-point the PRISMA guidelines. RESULTS: After an initial selection of 6995 titles, 15 articles were considered for the final qualitative analysis (n = 22 patients, including the present report). Conservative treatment was chosen in 12 cases (54.5%) with stable clinical conditions, while 9 patients (40.9%) required a primary operative approach for emergency presentation at diagnosis. Direct liver resection was the preferred surgical treatment (n = 6), mostly major hepatectomies (n = 4). Hepatic arterial embolization was performed as the primary operative approach in three patients, followed by emergency laparotomy during the same hospitalization because of rebleeding in one case. Contrast-enhanced CT scan was the gold standard for diagnosis (n = 19). CONCLUSIONS: Conservative treatment of SILH is mainly based on stable clinical conditions and may be considered even in case of a limited arterial blush found on imaging. The absence of underlying hepatic or systemic disorders seems to correlate with favorable outcomes and no mortality.

Combining Radiofrequency Ablation with Hepatic Resection for Liver-Only Colorectal Metastases: A Propensity-Score Based Analysis of Long-Term Outcomes.

BACKGROUND: Combining liver resection (LR) with radiofrequency ablation (RFA) is nowadays an accepted option for treating colorectal liver metastases (CRLMs), but the number of lesions ablated is regularly described as a recurrence risk factor. In this study, we report our experience and determine the impact of RFA on long-term outcomes. METHOD: This is a retrospective study including patients undergoing LR with or without RFA for CRLM. All variables influencing disease-free survival (DFS) and disease-specific survival (DSS) were examined through a Cox regression analysis before and after propensity-score matching (PSM). RESULTS: Among the 128 patients included, 71 (55.5%) underwent LR alone and 57 (44.5%) underwent LR+RFA. With univariate analysis, LR+RFA showed a significantly worse DFS than LR alone (p = 0.028), which was not confirmed after PSM (p = 0.064). Thermal ablation did not influence DSS before or after matching (p = 0.282 and p = 0.189). When analyzing the subgroups of patients according to number of RFAs performed, no difference in long-term outcomes was observed (after PSM: p = 0.192 for DFS and p = 0.624 for DSS). Analysis of site of recurrence revealed that neither performing an RFA (p = 0.893) nor the number of lesions ablated (p = 0.093, p = 0.550, and p = 0.087 for 1, 2, and ≥ 2 RFAs) were associated with an increased risk of liver-only relapse. DISCUSSION: In the setting of a parenchymal sparing strategy, combining RFA with LR is safe in terms of oncological outcomes. Tumor burden, rather than RFA performed, independently influences risk of recurrence and patient survival.

Defining Benchmark Outcomes for Distal Pancreatectomy: Results of a French Multicentric Study.

OBJECTIVE: Defining robust and standardized outcome references for distal pancreatectomy (DP) by using Benchmark analysis. BACKGROUND: Outcomes after DP are recorded in medium or small-sized studies without standardized analysis. Therefore, the best results remain uncertain. METHODS: This multicenter study included all patients undergoing DP for resectable benign or malignant tumors in 21 French expert centers in pancreas surgery from 2014 to 2018. A low-risk cohort defined by no significant comorbidities was analyzed to establish 18 outcome benchmarks for DP. These values were tested in high risk, minimally invasive and benign tumor cohorts. RESULTS: A total of 1188 patients were identified and 749 low-risk patients were screened to establish Benchmark cut-offs. Therefore, Benchmark rate for mini-invasive approach was ≥36.8%. Benchmark cut-offs for postoperative mortality, major morbidity grade ≥3a and clinically significant pancreatic fistula rates were 0%, ≤27%, and ≤28%, respectively. The benchmark rate for readmission was ≤16%. For patients with pancreatic adenocarcinoma, cut-offs were ≥75%, ≥69.5%, and ≥66% for free resection margins (R0), 1-year disease-free survival and 3-year overall survival, respectively. The rate of mini-invasive approach in high-risk cohort was lower than the Benchmark cut-off (34.1% vs ≥36.8%). All Benchmark cut-offs were respected for benign tumor group. The proportion of benchmark cases was correlated to outcomes of DP. Centers with a majority of low-risk patients had worse results than those operating complex cases. CONCLUSION: This large-scale study is the first benchmark analysis of DP outcomes and provides robust and standardized data. This may allow for comparisons between surgeons, centers, studies, and surgical techniques.

Evaluation of an Innovative Care Pathway in the Diagnostic and Therapeutic Management of Hepatobiliary and Pancreatic Pathologies: "One-Day Diagnosis".

"One-Day Diagnosis" (1DD) for hepatobiliary and pancreatic (HBP) diseases is an innovative care pathway that combines, on the same day, surgical consultation, medical imaging, anesthesia, diagnosis announcement, and therapeutic support consultations. The objective was to evaluate the length of the 1DD care pathway compared to a conventional one. The prospective "1DD care pathway" arm included 330 consecutive patients (January 2017−April 2019) vs. 152 (November 2014−November 2015) in the retrospective "conventional" one. In the 1DD group, diagnosis was made on the same day in 83% of consultations vs. 68.4% (p = 0.0005). Although there was no difference in overall time to diagnosis, diagnostic and therapeutic management was faster in the 1DD group (1 day vs. 15 days, p < 0.0004). In addition, 77% of patients who benefited from 1DD were very satisfied with their treatment overall. The mean cost of the 1DD consultation was EUR 176.8 +/− 149 (range: 50−546). The median cost of the overall program was similar (EUR 584 vs. EUR 563, p = 0.67). As an organizational innovation, the 1DD for HBP pathologies is a promising care pathway that optimizes diagnostic and therapeutic management, without creating medical overconsumption or additional costs. Given patient satisfaction, this model should be generalized to optimize cancer care by adapting it to the constraints of different healthcare structures.

Augmented Reality and Image-Guided Robotic Liver Surgery.

Artificial intelligence makes surgical resection easier and safer, and, at the same time, can improve oncological results. The robotic system fits perfectly with these more or less diffused technologies, and it seems that this benefit is mutual. In liver surgery, robotic systems help surgeons to localize tumors and improve surgical results with well-defined preoperative planning or increased intraoperative detection. Furthermore, they can balance the absence of tactile feedback and help recognize intrahepatic biliary or vascular structures during parenchymal transection. Some of these systems are well known and are already widely diffused in open and laparoscopic hepatectomies, such as indocyanine green fluorescence or ultrasound-guided resections, whereas other tools, such as Augmented Reality, are far from being standardized because of the high complexity and elevated costs. In this paper, we review all the experiences in the literature on the use of artificial intelligence systems in robotic liver resections, describing all their practical applications and their weaknesses.

Laparoscopic anatomical liver resection for malignancies using positive or negative staining technique with intraoperative indocyanine green-fluorescence imaging.

BACKGROUND: Indications for a minimally invasive resections are increasing worldwide, but respecting anatomical planes during intraparenchymal transection is demanding. Intraoperative ICG fluorescence staining of liver parenchyma has been introduced as a tool for real-time intraoperative guidance. The aim of this study is to make a systematic review of the current relevant literature on indications, techniques, and results of laparoscopic anatomical liver resection (LALR) using intraoperative indocyanine green (ICG) fluorescence for positive and negative staining of liver segments in patients affected by liver malignancies. METHODS: Electronic bibliographical databases (MEDLINE and PubMed) were searched according to the PRISMA criteria. English language articles meeting the selection criteria and published until June 2020 were retrieved and reviewed. RESULTS: a total of 86 articles were initially found and 11 articles were finally included in the analysis with a total of 83 patients treated. Sixty-two patients (74.6%) underwent mono-segmentectomies. Thirty-five patients (42.1%) underwent the positive staining technique, and forty-eight patients (57.8%) the negative staining technique. CONCLUSIONS: The positive or negative indocyanine green staining technique with real-time fluorescence guidance is an emerging and promising approach. However, the technique has to be standardized and advantages in terms of oncologic results still need validation in further studies.

A Standard Set of Value-Based Patient-Centered Outcomes for Pancreatic Carcinoma: An International Delphi Survey.

BACKGROUND: Global health systems are shifting toward value-based health care to improve patient outcomes in the face of rising health care costs. The challenge is to identify standardized outcome measurements that allow optimal quality-of-care monitoring and comparison to optimize medical practices and patient pathways. A common outcomes definition is required, including medical results (Clinical Reported Outcomes Measurements [CROMs]) and quality-of-life components that matter most to patients (Patient-Reported Outcomes Measurements [PROMs]), which are particularly important for severe pathologies with short life expectancy such as pancreatic cancer. This study aimed to create standardized metrics that could be used for outcomes analysis of pancreatic cancer care. METHODS: A multidisciplinary working group (WG) was assembled. A systematic review was performed to collect the most used outcomes in clinical studies of pancreatic cancers. The study reviewed 570 studies published in the last 10 years. From these studies, 3370 outcomes, including CROMs, and PROMs, were listed and prioritized. The WG reached a consensus on key outcomes, proposed groupings for CROMs and PROMs, identified existing questionnaires that could be used for PROMs collection, and set the timeline for data collection. To refine and validate the final outcomes set, an international external committee completed a Delphi process (two rounds for both CROMS and PROMs). RESULTS: After the systematic literature review, the WG selected 102 outcomes (92 CROMs and 10 PROMs) for submission to the international Delphi vote committee. The committee retrained 89 outcomes (78 CROMs and 11 PROMs). For the PROMs, the WG and the international external committee chose a validated questionnaire, the Functional Assessment of Cancer Therapy-Hepatobiliary, which covers all of the 11 selected PROMs. CONCLUSIONS: A standardized set of outcome measures that need to be validated through international health outcome comparisons and quality-of-care assessments was built. Pilot projects are underway to test and optimize the approach in real-life conditions.

Acute abdomen in patients with SARS-CoV-2 infection or co-infection.

PURPOSE: Patients with an acute abdomen require emergency surgery. SARS-CoV-2 infection can affect multiple organ systems, including the digestive tract. Little is known about the consequences of COVID-19 infection in emergency surgical patients. METHODS: Perioperative data for COVID-19 patients undergoing emergency surgery from March 1, 2020, to May 23, 2020 were collected prospectively (NCT04323644). RESULTS: During this period, 215 patients underwent surgery, including 127 patients in an emergency setting, of whom 13 (10.2%) had COVID-19. Two scenarios were identified: (a) patients who were admitted to a hospital for an acute surgical condition with a concomitant diagnosis of COVID-19, and (b) patients with severe COVID-19 developing acute abdominal pathologies during their hospital stay. When compared with those in group B, patients in group A globally recovered better, with a lower mortality rate (14.3% vs. 33.3%), lower ARDS rate (28.5% vs. 50.0%), less rates of preoperative invasive ventilation (14.3% vs. 50.0%) and postoperative invasive ventilation (28.5% vs. 100.0%), and a shorter duration of invasive ventilation. No causality between SARS-CoV-2 infection and gastrointestinal affliction was found. CONCLUSION: Our observations underline that mild co-infection with COVID-19 did not result in more complications for emergency abdominal surgery. Howe, an acute abdomen during severe COVID-19 infection was part of an unfavorable prognosis.

Robotic Central Pancreatectomy for Well-Differentiated Neuroendocrine Tumor: Parenchymal-Sparing Procedure.

BACKGROUND: The frequency of pancreatic neuroendocrine tumors (pNETs), representative of benign and borderline malignant pancreatic tumors, has been increasing. For pNETs, pancreas-preserving pancreatectomy can be an appropriate option. Conversely, some articles have recently shown that robotic central pancreatectomy (RCP) is feasible and safe. METHODS: We demonstrated our standardized technique of RCP. In our technique, pancreaticoenteric reconstruction is performed via a pancreaticogastrostomy to manage the distal pancreatic remnant. We also evaluated our initial experience with four consecutive RCPs for well-differentiated pNETs, retrospectively. RESULTS: In our evaluation, two men and two women had a median age of 45 years (range 36-64). Median tumor size was 2.1 cm (range 1-5), and median operative time was 315 min (range 268-630). No transfusion was given perioperatively. Median hospital stay was 17 days (range 13-22). Grade A postoperative pancreatic fistula was identified in two patients, while grade B was identified in the other two patients. One of the patients was managed using an additional percutaneous drainage. No operative mortality was observed. Pathological findings confirmed R0 resection for all well-differentiated pNETs (pT1: two patients; pT2: two patients). CONCLUSIONS: Central pancreatectomy can be carefully selected as a relevant surgical option for well-differentiated pNETs circumscribed in the pancreatic isthmus and body. Our robotic procedure might overcome the complexity of central pancreatectomy, a parenchymal-preserving procedure, with adequate oncological outcomes.

Aberrant splenic artery rising from the superior mesenteric artery: a rare but important anatomical variation.

Aberrant splenic artery originating from the superior mesenteric artery (SMA) is extremely rare and recognition of this anomaly is important in the pre-operative planning of complex surgery such as pancreatic surgery, liver transplantation and vascular surgery. We present the case of an 80-year-old female diagnosed as septic shock due to mesenteric ischemia and obstructive pyelonephritis. Her splenic artery was originating from the SMA and the anomaly was readily appreciated on the pre-operative CT images. An explorative laparotomy associating extensive small bowel resection with endarterectomy of the proximal part of the SMA was performed. During intra-operative SMA control, we confirmed the aberrant splenic artery arising from SMA, and successfully avoid any arterial injury on the splenic artery with isolation and separated proximal and distal clamping. The anatomical vascular variation should be recognized in the pre-operative work-up of a determined surgical procedure to avoid potential intra-operative arterial injuries.

Laparoscopic Hepatectomy Versus Open Hepatectomy for the Management of Hepatocellular Carcinoma: A Comparative Study Using a Propensity Score Matching.

OBJECTIVES: The aim of this study was to compare the results between laparoscopic hepatectomy and open hepatectomy in two French university hospitals, for the management of hepatocellular carcinoma (HCC) using a propensity score matching. MATERIALS AND METHODS: A patient in the laparoscopic surgery group (LA) was randomly matched with another patient in the open approach group (OA) using a 1:1 allocated ratio with the nearest estimated propensity score. Matching criteria included age, presence of comorbidities, American Society of Anesthesiologists score, and resection type (major or minor). Patients of the LA group without matches were excluded. Intraoperative and postoperative data were compared in both groups. Survival was compared in both groups using the following matching criteria: number and size of lesions, alpha-fetoprotein rate, and cell differentiation. RESULTS: From January 2012 to January 2017, a total of 447 hepatectomies were consecutively performed, 99 hepatectomies of which were performed for the management of hepatocellular carcinomas. Forty-nine resections were performed among the open approach (OA) group (49%), and 50 resections were performed among the laparoscopic surgery (LA) group (51%). Mortality rate was 2% in the LA group and 4.1% in the OA group. After propensity score matching, there was a statistical difference favorable to the LA group regarding medical complications (54.55% versus 27.27%, p = 0.04), and operating times were shorter (p = 0.03). Resection rate R0 was similar between both groups: 90.91% (n = 30) in the LA group and 84.85% (n =) in the OA group. There was no difference regarding overall survival (p = 0.98) and recurrence-free survival (p = 0.42). CONCLUSIONS: Laparoscopic liver resection for the management of HCC seems to provide the same short-term and long-term results as compared to the open approach. Laparoscopic liver resections could be considered as an alternative and become the gold standard in well-selected patients.

Laparoscopic management of neuroendocrine tumors: state-of-the-art.

Over recent years, minimally invasive pancreatic resections have increasingly been reported in the literature. Even though pancreatic surgery is still considered a challenge for surgeons due to its technical difficulties and high morbidity, the consolidation of minimally invasive pancreatic surgery has included the treatment of pancreatic neuroendocrine tumors (PNETs). This article presents a systematic review of the literature with regards to the laparoscopic treatment of PNETs in order to assess the safety and feasibility of laparoscopic pancreatic resections.

New Approaches in Locoregional Therapies for Hepatocellular Carcinoma.

PURPOSE: Hepatocellular carcinoma (HCC) represent actually the fifth most common cancer worldwide, with liver transplantation and hepatic resection who represent the standard of care of curative treatment. Unfortunately, not all patient could benefit of curative treatment. For such patients, locoregional or systemic therapies represent a valid option in order to achieve the best survival possible. METHODS: A review of most interesting paper actually present in literature on locoregional treatment for nonresectable nontransplantable HCC was performed. RESULTS: A detailed description on each different approach has been detailed in each chapter. CONCLUSION: In case of nontransplantable and nonresectable HCC, locoregional treatment represent a valid alternative in management of this patients.

Innovative surgical approaches for hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide, with an increasing diffusion in Europe and the United States. The management of such a cancer is continuously progressing and the objective of this paper is to evaluate innovation in the surgical treatment of HCC. In this review, we will analyze the modern concept of preoperative management, the role of laparoscopic and robotic surgery, the intrao-perative use of three dimensional models and augme-nted reality, as well as the potential application of fluore-scence.