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Background/Purpose: Quality measures in surgery are important to establish appropriate levels of care and to develop improvement strategies. The purpose of this study was to provide risk‐adjusted outcome measures after laparoscopic liver resection (LLR). Methods: Data from a prospective, multicenter database involving 4318 patients submitted to LLRs in 41 hospitals from an intention‐to‐treat approach (2014–2020) were used to analyze heterogeneity (I2) among centers and to develop a risk‐adjustment model on outcome measures through multivariable mixed‐effect models to account for confounding due to case‐mix. Results: Involved hospitals operated on very different patients: the largest heterogeneity was observed for operating in the presence of previous abdominal surgery (I2:79.1%), in cirrhotic patients (I2:89.3%) suffering from hepatocellular carcinoma (I2:88.6%) or requiring associated intestinal resections (I2:82.8%) and in regard to technical complexity (I2 for the most complex LLRs: 84.1%). These aspects determined substantial or large heterogeneity in overall morbidity (I2:84.9%), in prolonged in‐hospital stay (I2:86.9%) and in conversion rate (I2:73.4%). Major complication had medium heterogeneity (I2:46.5%). The heterogeneity of mortality was null. Risk‐adjustment accounted for all of this variability and the final risk‐standardized conversion rate was 8.9%, overall morbidity was 22.1%, major morbidity was 5.1% and prolonged in‐hospital stay was 26.0%. There were no outliers among the 41 participating centers. An online tool was provided. Conclusions: A benchmark for LLRs including all eligible patients was provided, suggesting that surgeons can act accordingly in the interest of the patient, modifying their approach in relation to different indications and different experience, but finally providing the same quality of care. [ABSTRACT FROM AUTHOR]

Pheochromocytoma is a tumor that has the probability to relapse in about 10% of surgically treated cases. Currently, the only recognized criteria of malignancy in these neoplasms are the evidence of metastasis at non-chromaffin sites. No reliable clinical or histopathological parameter has been, so far, identified to predict malignancy in patients with diagnosis of primary pheochromocytoma. Several authors has attempted to propose morphologic features to detect potentially malignant pheochromocytomas, but there are still too many reported cases of recurrence, also after decades, in tumors that, according to the current knowledge, are considered "benign". Here we report a case of recurrence, after 25 years, of a pheochromocytoma that had not enough criteria to be considered as malignant. [ABSTRACT FROM AUTHOR]

Objective: To evaluate improvements in operative and long-term results following surgery for hilar cholangiocarcinoma. Design: Retrospective multicenter study including 17 Italian hepatobiliary surgery units. Patients: A total of 440 patients who underwent resection for hilar cholangiocarcinoma from January 1, 1992, through December 31, 2007. Main Outcome Measures: Postoperative mortality, morbidity, overall survival, and disease-free survival. Results: Postoperative mortality and morbidity after liver resection were 10.1% and 47.6%, respectively. At multivariate logistic regression, extent of resection (right or right extended hepatectomy) and intraoperative blood transfusion were independent predictors of postoperative mortality (P=.03 and P=.006, respectively); in patients with jaundice, mortality was also higher without preoperative biliary drainage than with biliary drainage (14.3% vs 10.7%). During the study period, there was an increasingly aggressive approach, with more frequent caudate lobectomies, vascular resections, and resections for advanced tumors (T stage of 3 or greater and tumors with poor differentiation). Despite the aggressive approach, the blood transfusion rate decreased from 81.0% to 53.2%, and mortality slightly decreased from 13.6% to 10.8%. Median overall survival significantly increased from 16 to 30 months (P=.05). At multivariate analysis, R1 resection, lymph node metastases, and T stage of 3 or greater independently predicted overall and disease-free survival. Conclusions: Surgery for hilar cholangiocarcinoma has improved with decreased operative risk despite a more aggressive surgical policy. Long-term survival after liver resection has also increased, despite the inclusion of cases with more advanced hilar cholangiocarcinoma. Preoperative biliary drainage was a safe strategy before right or right extended hepatectomy in patients with jaundice. Pathologic factors independently predicted overall and disease-free survival at multivariate analysis. [ABSTRACT FROM AUTHOR]

Objective: To compare the outcomes of robotic minor liver resections (RMLR) versus laparoscopic (L) MLR of the anterolateral segments., Background: Robotic liver surgery has been gaining prominence over the years with increasing usage for a myriad of hepatic resections. Robotic liver resections(RLR) has demonstrated non-inferiority to laparoscopic(L)LR while illustrating advantages over conventional laparoscopy especially for technically difficult and major LR. However, the advantage of RMLR for the anterolateral(AL) (segments II, III, IVb, V and VI) segments, has not been clearly demonstrated., Methods: Between 2008 to 2022, 15,356 of 29,861 patients from 68 international centres underwent robotic(R) or laparoscopic minor liver resections (LMLR) for the AL segments Propensity score matching (PSM) analysis was performed for matched analysis., Results: 10,517 patients met the study criteria of which 1,481 underwent RMLR and 9,036 underwent LMLR. A PSM cohort of 1,401 patients in each group were identified for analysis. Compared to the LMLR cohort, the RMLR cohort demonstrated significantly lower median blood loss (75ml vs. 100ml, P<0.001), decreased blood transfusion (3.1% vs. 5.4%, P=0.003), lower incidence of major morbidity (2.5% vs. 4.6%, P=0.004), lower proportion of open conversion (1.2% vs. 4.5%, P<0.001), shorter post operative stay (4 days vs. 5 days, P<0.001), but higher rate of 30-day readmission (3.5% vs. 2.1%, P=0.042). These results were then validated by a 1:2 PSM analysis. In the subset analysis for 3,614 patients with cirrhosis, RMLR showed lower median blood loss, decreased blood transfusion, lower open conversion and shorter post operative stay than LMLR., Conclusion: RMLR demonstrated statistically significant advantages over LMLR even for resections in the AL segments although most of the observed clinical differences were minimal., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To compare minimally invasive and open pancreatoduodenectomy in different subtypes of ampullary adenocarcinoma., Summary Background Data: Ampullary adenocarcinoma (AAC) is widely seen as the best indication for minimally invasive pancreatoduodenectomy (MIPD) due to the lack of vascular involvement and dilated bile and pancreatic duct. However, it is unknown whether outcomes of MIPD for AAC differ between the pancreatobiliary (AAC-PB) and intestinal (AAC-IT) subtypes as large studies are lacking., Methods: This is an international cohort study, encompassing 27 centers from 12 countries. Outcome of MIPD and open pancreatoduodenectomy (OPD) were compared in patients with AAC-IT and AAC-PB. Primary end points were R1 rate, lymph node yield, and 5-year overall survival (5yOS)., Results: Overall, 1187 patients after MIPD for AAC were included, of whom 572 with AAC-IT (62 MIPD, 510 OPD) and 615 with AAC-PB (41 MIPD and 574 OPD). The rate of R1 resection was not significantly different between MIPD and OPD for both AAC-IT (3.4% vs 6.9%, P=0,425) and AAC-PB (9.8% vs 14.9%, P=0,625). AAC-IT, more lymph nodes were resected with MIPD group (19 vs 16, P=0.007), compared to OPD. The 5y-OS did not differ after MIPD and OPD for both AAC-IT (56.8% vs 59.5%, P=0.827 and AAC-PB (52.5% vs 44.4%, P=0.357). The rates of surgical complication between MIPD and OPD did not differ between AmpIT and AmpPB., Discussion: This international multicenter study found no differences in outcomes between MIPD and OPD for AAC-IT and AAC-PB. MIPD and OPD demonstrated comparable outcomes in oncological resection, survival and surgical outcomes for both subtypes of AAC., Competing Interests: Conflicts of interests: Mario Serradilla-Martín received research funding from Baxter S.L.. Patrick Pessaux is co-founder of Virtualisurg; Geert Kazemier is Chairman of the Advisory Board of Renovaro Inc.; Marc G. Besselink has received grants from Intuitive for the LEARNBOT European robot Whipple training program, the DIPLOMA-2 trial, and the E-MIPS quality registry, from Medtronic for the investigator-initiated DIPLOMA trial and from Ethicon for the PANDORA trial and the E-MIPS quality registry; Mohammed Abu Hilal received funding from Associazione Italiana per la Ricerca sul Cancro (AIRC); All remaining authors claim no conflicts of interests and no disclosures., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Single large hepatocellular carcinoma >5cm (SLHCC) traditionally requires a major liver resection. Minor resections are often performed with the goal to reduce morbidity and mortality. Aim of the study was to establish if a major resection should be considered the best treatment for SLHCC or a more limited resection should be preferred., Methods: A multicenter retrospective analysis of the HE.RC.O.LE.S. Group register was performed. All collected patients with surgically treated SLHCC were divided in 5 groups of treatment (major hepatectomy, sectorectomy, left lateral sectionectomy, segmentectomy, non-anatomical resection) and compared for baseline characteristics, short and long-term results. A propensity-score weighted analysis was performed., Results: 535 patients were enrolled in the study. Major resection was associated with significantly increased major complications compared to left lateral sectionanectomy, segmentectomy and non-anatomical resection (all p<0.05) and borderline significant increased major complications compared to sectorectomy (p=0.08). Left lateral sectionectomy showed better overall survival compared to major resection (p=0.02), while other groups of treatment resulted similar to major hepatectomy group for the same item. Absence of oncological benefit after major resection and similar outcomes among the 5 groups of treatment was confirmed even in the sub-population excluding patients with macrovascular invasion., Conclusion: Major resection was associated to increased major post-operative morbidity without long-term survival benefit; when technically feasible and oncologically adequate, minor resections should be preferred for the surgical treatment of SLHCC., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

This international multicenter cohort study included 30 centers. Patients with duodenal adenocarcinoma (DAC), intestinal-type (AmpIT) and pancreatobiliary-type (AmpPB) ampullary adenocarcinoma, distal cholangiocarcinoma (dCCA), and pancreatic ductal adenocarcinoma (PDAC) were included. The primary outcome was 30-day or in-hospital mortality, and secondary outcomes were major morbidity (Clavien-Dindo 3b≥), clinically relevant post-operative pancreatic fistula (CR-POPF), and length of hospital stay (LOS). Results: Overall, 3622 patients were included in the study (370 DAC, 811 AmpIT, 895 AmpPB, 1083 dCCA, and 463 PDAC). Mortality rates were comparable between DAC, AmpIT, AmpPB, and dCCA (ranging from 3.7% to 5.9%), while lower for PDAC (1.5%, p = 0.013). Major morbidity rate was the lowest in PDAC (4.4%) and the highest for DAC (19.9%, p < 0.001). The highest rates of CR-POPF were observed in DAC (27.3%), AmpIT (25.5%), and dCCA (27.6%), which were significantly higher compared to AmpPB (18.5%, p = 0.001) and PDAC (8.3%, p < 0.001). The shortest LOS was found in PDAC (11 d vs. 14-15 d, p < 0.001). Discussion: In conclusion, this study shows significant variations in perioperative mortality, post-operative complications, and hospital stay among different periampullary cancers, and between the ampullary subtypes. Further research should assess the biological characteristics and tissue reactions associated with each type of periampullary cancer, including subtypes, in order to improve patient management and personalized treatment.

Background and Aim: Diabetes mellitus is one of the major causes of end stage renal disease. After 10-15 years from the onset 30% of diabetic patients present nephropathy, and once haemodialysis is required, morbidity is particularly high and long-term survival is lower than in non-diabetic patients. Currently, it is demonstrated that simultaneous pancreas-kidney transplantation (SPK) shows beneficial effects on patient survival, on some diabetic degenerative complications and on the quality of life. Aim of the work is to report our experience in pancreas transplantation., Methods: From June 1998 to June 2005 17 type I diabetic uremic patients underwent SPK. Donor selection considered hemodynamically stable young patients without cardiac arrest or vasopressor drug excess and with a brief Intensive Care Unit hospitalization. Average donor age was 26 years (range 16-38). The cause of death was trauma for 14 donors (82.4%) and spontaneous cerebral hemorrhage for 3 donors (17.6%). Average pancreas cold ischemic time was 716 minutes (range 320-968)., Results: No patient mortality was observed. No primary or delayed graft function was observed both for pancreas and kidney. Biopsy proved the occurrence of acute rejection episode in one patient (5.8%). Five surgical (29.4%) and 2 medical (11.7%) complications developed. At a median follow-up of 36.4 months (range 4.2-88) patient survival rate was 100%. Pancreas and kidney graft survival rate was 76.5% and 94.1%, respectively. All patients referred an improvement in their quality of life., Conclusions: SPK represents a well-established therapy for uremic type I diabetes mellitus since it improves patient survival in selected recipients. Our experience, as reported in literature, confirm that a successful pancreas transplantation not only brings the recipient back to normal glycemic levels, but it also improves the patient's quality of life by stabilizing some of the secondary complications of diabetes.

Renal allograft rupture (RAR) is a rare but potentially serious complication in the transplanted recipients. The most common cause is acute rejection. We report four cases (0.5%) of RAR occurred in a series of 778 consecutive kidney transplantations due to severe acute tubular necrosis and renal vein thrombosis with no evidence of acute rejection. Transplant nephrectomy was performed in three patients, whereas graft repair was achieved in one patient. These data suggest that RAR may be associated with renal vein thrombosis or severe acute tubular necrosis in absence of acute rejection. Frequently nephrectomy is necessary, but conservative surgical treatment should be attempted to preserve the allograft in selected cases.