18 research outputs found

    Implementing a robotic liver resection program does not always require prior laparoscopic experience

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    Background: Preliminary experience in laparoscopic liver surgery is usually suggested prior to implementation of a robotic liver resection program. Methods: This was a retrospective cohort analysis of patients undergoing robotic (RLR) versus laparoscopic liver resection (LLR) for hepatocellular carcinoma at a center with concomitant initiation of robotic and laparoscopic programs RESULTS: A total of 92 consecutive patients operated on between May 2014 and February 2019 were included: 40 RLR versus 52 LLR. Median age (69 vs. 67; p = 0.74), male sex (62.5% vs. 59.6%; p = 0.96), incidence of chronic liver disease (97.5% vs.98.1%; p = 0.85), median model for end-stage liver disease (MELD) score (8 vs. 9; p = 0.92), and median largest nodule size (22 vs. 24 mm) were similar between RLR and LLR. In the LLR group, there was a numerically higher incidence of nodules located in segment 4 (20.0% vs. 16.6%; p = 0.79); a numerically higher use of Pringle's maneuver (32.7% vs. 20%; p = 0.23), and a shorter duration of surgery (median of 165.5 vs. 217.5 min; p = 0.04). Incidence of complications (25% vs.32.7%; p = 0.49), blood transfusions (2.5% vs.9.6%; p = 0.21), and median length of stay (6 vs. 5; p = 0.54) were similar between RLR and LLR. The overall (OS) and recurrence-free (RFS) survival rates at 1 and 5 years were 100 and 79 and 95 and 26% for RLR versus 96.2 and 76.9 and 84.6 and 26.9% for LLR (log-rank p = 0.65 for OS and 0.72 for RFS). Conclusions: Based on our results, concurrent implementation of a robotic and laparoscopic liver resection program appears feasible and safe, and is associated with similar oncologic long-term outcomes

    Sistemi di perfusione ex situ/ex vivo del graft epatico

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    Introduction Over the years, new strategies have allowed to increase the number of transplantable livers, expanding the selection criteria to the extendend criteria donors (ECD), for example elderly donors and donation after cardiac death (DCD). Unfortunately, these grafts present a higher incidence of liver damage and biliary complications. The introduction of the Machine Perfusion (MP), an ex situ perfusion technique, allows a partial reconditioning of the organ before transplant. Methods All DCD liver transplants performed at Unit of Liver Surgery and Transplantation of Pisa from 1 January 2018 to 31 December 2022 were included in the study. In addition transplants from DBD (Donation after brain death) donors subjected to Normothermic machine perfusion (NMP) or Dual hypothermic oxygenated perfusion (D-HOPE) performed in the same period were included. Since December 2020 the DCD transplants performed at our Center have been included in a randomized and multicenter study protocol called DCD-Net, with the aim of comparing the results of D-HOPE vs NMP in DCD liver transplants. Results 30 DCD transplants were performed at our Center: 11 grafts underwent D-HOPE, while NMP was performed on 19 grafts. In the NMP group there were 6 cases of early allograft dysfunction (EAD) and one case of re-transplantation; survival was found to be 89% at one and 77% at three years. In the D-HOPE group there were 5 cases of EAD; survival was found to be 80% at one and 3 years. Six patients (5 NMP, 1 D-HOPE) presented biliary complications. The last 20 DCDs have been entered in the DCD-Net protocol; the only statistically significant difference between the two groups was the number of EAD, higher in the D-HOPE gioup (p = 0.025). There were 29 DBD grafts subjected to MP, 10 subjected to NMP and 19 to D-HOPE. No significant differences were found between the two groups. Discussion The results of the DCD donation were in line with the literature regarding biliary complications, graft loss and re-transplantation. More unfavorable results were obtained concerning hospitalization days, perioperative and one-year mortality. The use of ex situ perfusion systems has considerable potential for a greater procurement of organs. However, no decisive results have been obtained to favor the use in NMP or D-HOPE, mainly due to the small number of transplants performed from DCD donors

    La chirurgia pancreatica nel paziente anziano ad alto rischio

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    Introduzione: negli ultimi decenni il miglioramento delle condizioni socio-economiche e i progressi della medicina hanno determinato, soprattutto nei Paesi più avanzati, un aumento della popolazione anziana e, al tempo stesso, un incremento dell'incidenza di molte patologie tumorali e quindi la necessità di trattare pazienti con età sempre più elevata. In particolare, i centri che si occupano di chirurgia pancreatica si trovano sempre più frequentemente a occuparsi di pazienti anziani con comorbidità importanti. Pertanto diviene necessario valutare i risultati di questo tipo di chirurgia nelle fasce di età più elevate e nei pazienti che, a causa di patologie preesistenti, presentano un alto rischio operatorio. Lo scopo di questo elaborato è quello di valutare l'outcome di pazienti anziani ad alto rischio operatorio (ASA, American Society of Anesthesiologists) sottoposti a interventi di chirurgia resettiva pancreatica, in confronto a soggetti più giovani e a pazienti della stessa fascia di età ma rischio anestesiologico più basso. Pazienti e metodi: abbiamo analizzato le caratteristiche cliniche, operatorie e post-operatorie di 345 pazienti sottoposti a resezione pancreatica negli anni 2010-2017 presso l'S. D. di Chirurgia Generale. I soggetti sono stati sottoposti a duodenocefalopancreasectomia (DCP), pancreasectomia sinistra, pancreasectomia totale, pancreasectomia intermedia, enucleoresezione o a intervento chirurgico per pseudocisti pancreatica. I pazienti sono stati suddivisi in tre gruppi in base all'età: < 65 anni (Gruppo A), 65-74 anni (Gruppo B), ≥ 75 anni (Gruppo C). Risultati: dei 345 paziente, 117 facevano parte del gruppo A (33.9%), 128 del Gruppo B (37.1%) e 100 del Gruppo C (29.0%). I pazienti di età avanzata presentavano più frequentemente gravi comorbidità rispetto ai pazienti più giovani, in particolare per quanto riguarda patologie cardiovascolari, pneumopatie e diabete mellito, e un'incidenza maggiore di reinterventi e complicanze post-operatorie, quali fistole pancreatiche e ritardo di canalizzazione superiore. Tuttavia, la mortalità perioperatoria non è risultata significativamente più elevata nei pazienti più anziani rispetto ai pazienti dei gruppi A e B (p = 0,12 e p = 0,41 rispettivamente). Inoltre, all'interno del Gruppo C il confronto tra pazienti con diverso rischio operatorio non ha mostrato differenze significative riguardo a complicanze chirurgiche (p = 0,59), reinterventi (p = 0,45) e mortalità (p = 0,34): in particolare, tra i 18 pazienti con età maggiore a 75 anni e ASA 4, solo un paziente è stato sottoposto a reintervento e la mortalità è stata assente. Per quanto riguarda la sopravvivenza a lungo termine, i pazienti più anziani hanno presentato una sopravvivenza media significativamente minore rispetto agli altri due gruppi, ma la mortalità per patologia oncologica non è risultata significativamente diversa nel confronto tra i tre gruppi (p = 0,08 tra gruppi A e B, p = 0,05 tra i gruppi A e C, p = 0,78 tra i gruppi B e C). Prendendo in considerazione il sottogruppo ASA 4 dei più anziani, la sopravvivenza media non si è dimostrata statisticamente differente rispetto ai pazienti nella stessa fascia di età e con minore rischio anestesiologico (p = 0,53). Conclusioni: la nostra esperienza suggerisce che l'età avanzata non dovrebbe rappresentare un motivo per precludere ai pazienti anziani con patologia pancreatica o periampollare la possibilità di sottoporsi a intervento chirurgico con finalità curativa, sebbene essa sia legata a un maggior numero di complicanze postoperatorie e di reinterventi e a una sopravvivenza media minore. Infatti, la mortalità per malattia oncologica nei pazienti operati non è risultata differente tra il gruppo dei soggetti più anziani e gli altri due gruppi. Inoltre, anche l'elevato rischio anestesiologico (ASA 4) nei soggetti con età ≥ 75 anni non dovrebbe essere considerato, di principio, una controindicazione assoluta a una chirurgia potenzialmente curativa, in quanto la sopravvivenza a breve e a lungo termine è stata la medesima di quelli con rischio minore (ASA 1-3)

    Il trapianto di rene da vivente con scambio altruistico

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    Introduzione: Con AUPKE (Altruistic unbalanced paired kidney exchanges) o trapianto altruistico si intende il coinvolgimento di coppie donatore/ricevente compatibili in uno scambio con coppie donatore/ricevente incompatibili. Tale pratica consente, grazie ad un atto di generosità gratuita, di permettere trapianti da vivente altrimenti non effettuabili. In questo modo si riesce ad incrementare in maniera significativa il numero di trapianti da vivente, che, a seguito delle modifiche dell'epidemiologia della donazione, oggi sono la principale opzione trapiantologica per i giovani dializzati. L'AUPKE in Italia non è ancora realtà clinica, mentre negli Stati Uniti è stato realizzato con successo ed ha risolto condizioni di incompatibilità assoluta. Metodi: Obiettivo di questa tesi è quello di analizzare l'impatto potenziale dell'avvio di un programma di AUPKE sull'attività del Centro Trapianti di Pisa. Sono state coinvolte 46 coppie donatore/ricevente in un'indagine di opinione volta a sondare la loro volontà di partecipazione a questo tipo di programma. Un questionario validato, che indaga le attitudini e la sensibilità dei partecipanti nei confronti della donazione altruistica, comprendente 20 domande per il donatore e 23 domande per il ricevente, è stato autosomministrato a tutti i partecipanti. Inoltre, è stata effettuata una simulazione computerizzata per valutare l'impatto dell'avvio del programma di AUPKE sull'attività di trapianto da vivente del Centro. Attualmente, 59 pazienti sono in valutazione per un trapianto da vivente, avendo a disposizione 63 familiari disponibili a donare. Per 40 riceventi sono presenti uno o più donatori compatibili in modo diretto, mentre 19 hanno uno o più donatori disponibili ma non compatibili. Risultati: 40/46 coppie (87,0%) hanno riconsegnato il questionario compilato. L'età media dei riceventi è stata di 43,0 anni (range 21-70), 25 uomini e 15 donne; l'età media dei donatori è stata di 53,7 anni (range 36-74), 17 uomini e 23 donne. 15 donatori (37,5%) sono non consanguinei. Alle diverse domande una percentuale variabile tra il 2,5% ed il 20,0% dei riceventi ed una tra lo 0% e il 17,5% dei donatori non ha risposto. Dall'analisi delle risposte dei donatori e dei riceventi (D Vs R) emerge una disponibilità sostanziale di tutti gli intervistati ad uno scambio altruistico (D 35,0% Vs R 33,3%), a condizione però di un vantaggio in termini di età del donatore (D 42,5% Vs R 34,2%) e di compatibilità (D 51,3% Vs R 34,2%), purché ciò non comporti un ritardo nell'effettuare l'intervento superiore ai tre mesi (D 76,2% Vs R 70,9%), anche se gli interventi di donazione e trapianto dovessero essere eseguiti in città diverse (D 38,5% Vs R 35,1%). La piena condivisione della scelta altruistica con il proprio partner è considerata importante dal 73,0% dei donatori e dal 78,9% dei riceventi. Inoltre, la disponibilità aumenta se nell'altra coppia è compreso un familiare (D 45,9% Vs R 41,7%) od un minore (D 48,6% Vs R 54,1%). Lo scambio altruistico sarebbe fonte di stress per il 22,5% dei donatori e il 26,3% dei riceventi. Gran parte dei partecipanti vorrebbe conoscere l'altra coppia prima (D 37,5% Vs R 43,2%) o dopo (D 35,9% Vs R 50,0%) lo scambio, mentre la possibilità di un risultato negativo del trapianto sul proprio congiunto condizionerebbe il 15,4% dei donatori ed il 29,7% dei riceventi. Il 17,9% dei donatori ed il 16,2% dei riceventi sarebbe condizionato dalla mancata funzionalità del rene donato all'altra coppia. Il risultato della simulazione computerizzata ha mostrato la possibilità di eseguire un trapianto da vivente in 17/19 coppie incompatibili in valutazione (89,5%), utilizzando la disponibilità eventuale di 15 coppie compatibili a partecipare ad uno scambio altruistico. Conclusioni: L'AUPKE è percepito in modo positivo e pragmatico da parte dei soggetti coinvolti direttamente nel trapianto da vivente. Non emergono problematiche di ordine psicologico, culturale o religioso che limitino la disponibilità a donare o ricevere un rene altruisticamente. D'altra parte, l'attivazione di questo tipo di programma potrebbe essere efficace a risolvere le situazioni di incompatibilità che non consentono il trapianto per buona parte dei pazienti

    Everolimus versus mycophenolate mofetil in liver transplantation: every improvement in renal function matters

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    : The current edition of the journal features a Spanish, nationwide, multi-institutional study by Gomez Bravo MA et al. exploring the advantages of everolimus (EVR)-facilitated tacrolimus (TAC) minimization versus TAC in combination with mycophenolate mofetil (MMF) after liver transplantation (LT)

    Aging with a Liver Graft: Analysis of Very Long-Term Survivors after Liver Transplantation

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    Background: In Italy, data on long-term survivors after liver transplantation are lacking. Materials and Methods: We conducted a hybrid design study on a cohort of 359 adult recipients who received transplants between 1996 and 2002 to identify predictors of survival and the prevalence of co-morbidities among long-term survivors. Results: The actuarial (95% CI) patient survival was 96% (94.6–98.3%), 69% (64.2–73.6%), 55% (49.8–59.9%), 42.8% (37.6–47.8%), and 34% (29.2–38.9%) at 1, 5, 10, 15, and 20 years, respectively. The leading causes of death were hepatitis C virus recurrence (24.6%), extrahepatic malignancies (16.9%), infection (14.4%), and hepatocellular carcinoma recurrence (14.4%). The factors associated with the survival probability were younger donor and recipient ages (p = 0.001 and 0.004, respectively), female recipient sex (p p p = 0.001), and absence of diabetes mellitus at one year (p < 0.01). At the latest follow-up, the leading comorbidities were hypertension (53.6%), obesity (18.7%), diabetes mellitus (17.1%), hyperlipidemia (14.7%), chronic kidney dysfunction (14.7%), and extrahepatic malignancies (13.8%), with 73.9% of patients having more than one complication. Conclusions: Aging with a liver graft is associated with an increased risk of complications and requires ongoing care to reduce the long-term attrition rate resulting from chronic immunosuppression

    Less is more: an outcome assessment of patients operated for gallstone ileus without fistula treatment

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    Background The treatment of gallstone ileus (GI) consists of surgical removal of the impacted bilestone with or without cholecystectomy and repair of the biliodigestive fistula. The objective of this study was to assess whether sparing patients a definitive biliary procedure adversely influenced the outcome. Materials and methods Patients with a diagnosis of GI were reviewed. Two groups were identified: patients who underwent a definitive biliary procedure with relieving the intestinal obstruction (group 1/G1) and those who did not have a definitive biliary procedure (group 2/G2). In G2, patients were evaluated on long-term follow-up for the risk of recurrent GI disease, cholecystitis, cholangitis and gallbladder cancer. Results Among 1075 patients admitted for small bowel obstruction, 20 (1.9%) were diagnosed with gallstone ileus. 3 (15%) of these belong to G1, 17 (85%) to G2. The overall postoperative morbidity rate was 35% (7/20) with one complication exceeding grade II in each group. No deaths were reported. Mean follow-up was 50 months. During follow-up, one of G2 patients had recurrent disease. No biliary tract infections or gallbladder cancer were identified. Conclusion Enterolithotomy without fistula closure is confirmed to be safe and effective for the management of gallstone ileus both on a short- and long-term basis

    ROBOTIC ASSISTED VERSUS PURE LAPAROSCOPIC SURGERY OF THE ADRENAL GLANDS: A CASE-CONTROL STUDY COMPARING SURGICAL TECHNIQUES

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    AIM: The role of da Vinci® System in adrenal gland surgery is not well-defined yet. This case-controlled study aims to compare robotic assisted surgery with pure laparoscopic surgery, in the authors’ monocentric experience. MATERIALS AND METHODS: 116 patients underwent minimally invasive adrenalectomies in our Department between June 1994 and December 2014: 75 with pure laparoscopic surgery (LS), whereas 41 with da Vinci® robotic system (RS). This case-controlled study was performed comparing 19 patients operated with RS and 19 operated with LS according to BMI, age, laterality and neoplasia dimensions. The two groups were compared for clinical and surgical data. Patients of each group were divided in subgroups according to nodule dimensions (< 3 cm, between 3 and 6 cm, ≥ 6 cm). Statistical analysis was performed with Student’s t-test for independent samples. Value of p < 0.01 was considered significant. RESULTS: The laparoscopic group of this case-controlled study showed a significant increase of operative time in patients with malignancy, in those with BMI ≥ 30 kg/m2 and with nodules > 6 cm (p < 0.01). This trend was not evidenced in the robotic group (p = NS). The direct comparison between RS and LS did not reveal differences in the operative time with nodules < 3 cm or between 3 and 6 cm, whereas with nodules ≥ 6 cm the robotic group operative time resulted significantly lower compared to the laparoscopic group (163.3 vs. 276.4 minutes; p < 0.01). Conversions to open surgery were 2 for the laparoscopic group and 0 for the robotic group. Postsurgical complications were 2 and 0 respectively. No reoperations or deceased patients occurred. CONCLUSIONS: In our experience, robotic system in adrenal gland surgery showed potential benefits compared to classic laparoscopy in patients with malignancy, BMI ≥ 30 kg/m2 and neoplasia > 6 cm

    ROBOTIC ASSISTED VERSUS PURE LAPAROSCOPIC ADRENALECTOMY: A CASE-MATCHED STUDY

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    AIM: The role of da Vinci® System in adrenal gland surgery is not well-defined yet. This case-controlled study aims to compare robotic assisted surgery with pure laparoscopic surgery, in the authors’ monocentric experience. MATERIALS AND METHODS: 116 patients underwent minimally invasive adrenalectomies in our Department between June 1994 and December 2014: 75 with pure laparoscopic surgery (LS), whereas 41 with da Vinci® robotic system (RS). This case-controlled study was performed comparing 19 patients operated with RS and 19 operated with LS according to BMI, age, laterality and neoplasia dimensions. The two groups were compared for clinical and surgical data. Patients of each group were divided in subgroups according to nodule dimensions (< 3 cm, between 3 and 6 cm, ≥ 6 cm). Statistical analysis was performed with Student’s t-test for independent samples. Value of p < 0.01 was considered significant. RESULTS: The laparoscopic group of this case-controlled study showed a significant increase of operative time in patients with malignancy, in those with BMI ≥ 30 kg/m2 and with nodules >6 cm (p < 0.01). This trend was not evidenced in the robotic group (p = NS). The direct comparison between RS and LS did not reveal differences in the operative time with nodules < 3 cm or between 3 and 6 cm, whereas with nodules ≥ 6 cm the robotic group operative time resulted significantly lower compared to the laparoscopic group (163.3 vs. 276.4 minutes; p < 0.01). Conversions to open surgery were 2 for the laparoscopic group and 0 for the robotic group. Post-surgical complications were 2 and 0 respectively. No reoperations or deceased patients occurred. CONCLUSIONS: In our experience, robotic system in adrenal gland surgery showed potential benefits compared to classic laparoscopy in patients with malignancy, BMI ≥ 30 kg/m2 and neoplasia> 6 cm

    Advanced age and high American Society of Anesthesiologists’ risk score do not increase perioperative mortality in pancreatic resections: a view from a tertiary care center

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    Background and Objectives: To evaluate outcomes in elderly patients with high anaesthesiology risk (ASA 4) who underwent pancreatic resection compared to younger patients and elderly patients with lower anaesthesiology risk. Materials and Methods: A consecutive series of 345 patients who underwent pancreatic resection at our tertiary care centre between 2010 and 2017 was reviewed. We compared three groups based on age at the time of surgery:&lt;65 years (group A), 65-74 years (group B), and ³75 years (group C). In addition, patients in group C were split into two subgroups, ASA 1-3 versus ASA 4, and compared. Prospectively collected data regarding pre-, intra-, post-operative course and follow up of patients belonging to these two subgroups were retrospectively analysed and compared. Results: The group A consisted in 117 (34%) patients, the group B in 128 (37%) patients, and group C in 100 (29%) patients. Group C patients had a significant higher incidence of comorbidities and ASA 4 respect the other two groups (p&lt;0.05). The incidence of the overall post-operative complications was significantly higher in the group C (p&lt;0.01), due to the higher incidence of medical complications. No difference in term of overall surgical complications was reported between the three groups. No difference was documented for post-operative mortality between the three groups. The mean overall survival was significantly lower for group C (p&lt;0.01), but no difference in mortality for cancer was reported between the three groups. Within Group C, the comparison between patients with ASA score 1-3 and ASA 4 showed no significant differences regarding surgical complications (p=0.59), reoperation rate (p=0.45), mortality (p=0.34) and mean overall survival (p=0.53). Conclusion: Although elderly patients presented a higher rate of postoperative complications and a lower mean overall survival, they did not show a higher perioperative mortality. Furthermore, mortality due to cancer in operated patients was not different between the three groups. For these reasons, the advanced age should not be considered a reason to preclude the surgical option to elderly patients with pancreatic cancer . Furthermore, no differences were found in short-term and long-term survival in elderly patients with different operative risk factors (ASA score) , so the higher anesthesiological risk in subjects aged ≥ 75 years should not be considered an absolute contraindication to surgical treatment
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