Background:The outcomes of liver surgery worldwide remain unknown. The true population-based outcomes are likely different to those vastly reported that reflect the activity of highly specialized academic centers. The aim of this study was to measure the true worldwide practice of liver surgery and associated outcomes by recruiting from centers across the globe. The geographic distribution of liver surgery activity and complexity was also evaluated to further understand variations in outcomes.Methods:LiverGroup.org was an international, prospective, multicenter, cross-sectional study following the Global Surgery Collaborative Snapshot Research approach with a 3-month prospective, consecutive patient enrollment within January-December 2019. Each patient was followed up for 90 days postoperatively. All patients undergoing liver surgery at their respective centers were eligible for study inclusion. Basic demographics, patient and operation characteristics were collected. Morbidity was recorded according to the Clavien-Dindo Classification of Surgical Complications. Country-based and hospital-based data were collected, including the Human Development Index (HDI). (NCT03768141).Results:A total of 2159 patients were included from six continents. Surgery was performed for cancer in 1785 (83%) patients. Of all patients, 912 (42%) experienced a postoperative complication of any severity, while the major complication rate was 16% (341/2159). The overall 90-day mortality rate after liver surgery was 3.8% (82/2,159). The overall failure to rescue rate was 11% (82/ 722) ranging from 5 to 35% among the higher and lower HDI groups, respectively.Conclusions:This is the first to our knowledge global surgery study specifically designed and conducted for specialized liver surgery. The authors identified failure to rescue as a significant potentially modifiable factor for mortality after liver surgery, mostly related to lower Human Development Index countries. Members of the LiverGroup.org network could now work together to develop quality improvement collaboratives.

Objectives: Locally advanced pancreatic cancer (LAPC) is found in about 40% of patients with pancreatic cancer. Irreversible electroporation (IRE) is a nonthermal ablative technique that provides an alternative in patients with LAPC and can be safely combined with chemotherapy. Materials and Methods: From 2015 until October of 2019, we performed laparotomic IRE in a total of 40 patients with stage III LAPC. The median age of these patients was 65.2 years (range: 46 to 81 y), and the median tumor size was 3.8 cm (range: 2 to 5.2 cm). 33 of 40 patients were treated preoperatively with FOLFIRINOX or nab-paclitaxel plus gemcitabine and in case of disease control, IRE was performed, whereas in 7 patients, IRE was performed without previous chemotherapy. Results: All patients were treated successfully with IRE as the tumor evaluation showed no disease progression after the completion of induction chemotherapy. No IRE-related deaths occurred. Two major grade III complications were reported: pancreatic fistula grade A in 8 patients and 3 patients diagnosed with delayed gastric emptying. Up to October 31, 2019, the median overall survival (OS) of all patients was 24.2 months (range: 6 to 36 mo), and the median progression-free survival was 10.3 months (range: 3 to 24 mo). After the completion of IRE, 30 patients (75%) continued with adjuvant chemotherapy. Fifteen patients (37%) have >24 months OS and 3 patients (8%) have reached 36 months OS and are still alive. Conclusion: The combination of chemotherapy with IRE, which is a safe and effective procedure, may result in a survival benefit for patients with LAPC.

BACKGROUND:Irreversible Electroporation (IRE) is a novel non-thermal ablation technique used in patients with locally advanced pancreatic cancer (LAPC), in the proximity of sensitive structures such as vessels, intestinal wall and the bile duct. Currently, it is only used in the setting of clinical trials. This systematic review aimed to tackle the knowledge gap in the literature, in relation to the safety and efficacy of the open approach IRE.METHODS:MEDLINE, EMBASE and Cochrane libraries were searched for English language articles published from January 2000 to December 2019. Data related to safety and efficacy were extracted.RESULTS:Nine studies involving 460 patients with LAPC were included. Open approach IRE was associated with high morbidity (29.4%) but with a survival benefit compared to traditional treatment. Median overall survival (OS) was at 17.15 months. Major morbidity was at 10.2% and mortality at 3.4%.CONCLUSIONS:Despite the paucity of literature and the low quality of evidence, the results regarding safety and efficacy appear to be encouraging. The high morbidity seems to be mitigated by a demonstrated improvement in OS. The potential of this technique is more evident when mortality and major morbidity are considered, since they are at acceptable levels. The limitations of this review have made it difficult to extract definitive conclusions. Higher quality evidence is needed in the form of large-scale multicentre randomized controlled trials. It remains to be elucidated whether the rate of adverse events decreases as our experience with this technique increases.

Background ALPPS is found to increase the resectability of primary and secondary liver malignancy at the advanced stage. The aim of the study was to verify the surgical and oncological outcome of ALPPS for intrahepatic cholangiocarcinoma (ICC). Methods The study cohort was based on the ALPPS registry with patients from 31 international centers between August 2009 and January 2018. Propensity score matched patients receiving chemotherapy only were selected from the SEER database as controls for the survival analysis. Results One hundred and two patients undergoing ALPPS were recruited, 99 completed the second stage with median inter-stage duration of 11 days. The median kinetic growth rate was 23 ml/day. R0 resection was achieved in 87 (85%). Initially high rates of morbidity and mortality decreased steadily to a 29% severe complication rate and 7% 90-day morbidity in the last 2 years. Post-hepatectomy liver failure remained the main cause of 90-day mortality. Multivariate analysis revealed insufficient future liver remnant at the stage-2 operation (FLR2) to be the only risk factor for severe complications (OR 2.91, p = 0.02). The propensity score matching analysis showed a superior overall survival in the ALPPS group compared to palliative chemotherapy (median overall survival: 26.4 months vs 14 months; 1-, 2-, and 3-year survival rates: 82.4%, 70.5% and 39.6% vs 51.2%, 21.4% and 11.3%, respectively, p < 0.01). The survival benefit, however, was not confirmed in the subgroup analysis for patients with insufficient FLR2 or multifocal ICC. Conclusion ALPPS showed high efficacy in achieving R0 resections in locally advanced ICC. To get the most oncological benefit from this aggressive surgery, ALPPS would be restricted to patients with single lesions and sufficient FLR2.

The prevalence of pancreatic ductal adenocarcinoma (PDAC) is increasing in the western world, being currently on of the leading causes of mortality. Surgical resection provides best chances of cure but, unfortunately, less than 20% of the patients are eligible for curative intent surgery at the time of diagnosis. Chemotherapeutic agents such as FOLFIRINOX have been used in patients with metastatic or locally advanced disease showing survival benefit. Methods: In this pilot study, we present an early initial experience with neoadjuvant FOLFIRINOX as first line therapy for locally advanced and non resectable PDAC highlighting the toxicity and complete resection rates as well as overall survival. Results: Roughly every patient experienced toxicity according to ECOG criteria with a median recorded event up to 6, most of them grade I and grade II. One third of the patients had downsizing of tumor, however only 43.3% of them ended up having resectable disease. A R0 resection was achieved in 10 of the patients (76.9%). Median follow up for the entire study was 14 months. Fourteen patients (46.6%) had stable disease and 7 (23.3%) had tumor-related death. Approximately 30% of the patients were in remission by the end of follow up. Considering the above results patients that had good response to FOLFIRINOX and underwent R0 surgical treatment had increased their median survival to 30 months compared to those who did not have oncological tumor resection (13 months). Conclusions: FOLFIRINOX is an effective treatment regimen that manages to convert unresectable-at diagnosis PDACto resectable with increased survival. However, due to high toxicity, treatment is only feasible in selected patients and requires close monitoring.

Bronchobiliary fistula (BBF) is a rare complication following hepatectomy, and consists of an abnormal intercommunication between the biliary tract and bronchial tree. The management of this rare entity is challenging with limited current evidence to date on how to treat this condition. Herein, a case of BBF following a central hepatectomy and the successive steps of the management was presented. Fourteen months postoperatively, the patient presented to the Oncology Department complaining of new onset fever and expectoration. A computerized tomography scan revealed a BBF and the patient was subsequently referred to our department for further treatment. The surgical team decided that a further operation was required. Using the transabdominal approach, a communication between the initial intrahepatic collection and one inferior lobular bronchus was revealed. Transhiatal removal of fistula was performed with closure of the defect through the abdomen. There was no bile leak through the remaining liver parenchyma. Multidisciplinary management should be considered, taking into consideration the underlying pathology leading to this rare complication. Conservative treatment should be considered first, while surgical resection of the BBF remains an option when other therapies have failed. Surgeons should be aware of this rare complication bile duct injuries during hepatic operations can cause.

Background: Irreversible electroporation (IRE) has been recently standardized as an additional therapeutic option in patients with locally advanced pancreatic cancers (LAPC) involving vital structures and vessels. IRE delivers electric current to obtain irreversible changes in cell membrane leading to cell death. The aim of this study was to evaluate the long-term effects and survival of IRE in the treatment of LAPC.

e15723 Background: LAPC represents 40% of PC pts. IRE is a non-thermal ablative technique that can be used in inoperable pts and safely combined with C. Methods: From 2015 to 2018 laparotomic IRE was performed in a total of 34 LAPC pts. The median age was 64.7yrs (range, 46-81yrs) and 15 (44%) were males. The median tumor size was 3.9cm (range, 2-5.2cm) with the majority of tumors located at pancreatic head (26 pts, 76%), followed by body (6 pts, 18%) and tail of pancreas (2 pts, 6%). Induction C was applied in 27 out of 34 pts and in case of disease control IRE was done, while in 7 pts IRE was done without prior C. In the majority of pts C after IRE was also given. Results: Induction C was applied in 27 out to 34 pts (80%) [FOLFIRINOX in 16 pts, nab-paclitaxel-gemcitabine (AG) in 11 pts]. After the completion of 3 cycles of C tumor evaluation showed partial response (PR) in 20 pts and stable disease (SD) in 7 pts. All pts were treated with IRE and 50% of them had a preoperative biliary stent, while 3 pts had metallic stent that was removed before IRE. No IRE-related deaths occurred. Two major complications grade III were reported: pancreatic fistula grade A in 7 pts and 2 pts diagnosed with delayed gastric emptying. There was also one minor complication (wound infection) in 3 pts (9%). Up to 31/12/2018, the median overall survival (OS) of all pts was 24.2 months (mos) (range, 6-36 mos) and median progression free survival (PFS) was 14.6 mos (range, 3-24 mos). The median OS of the pts treated with C-IRE-C was 22.5 mos (range, 13-36 mos) and median PFS 16.9 mos (range, 3-24 mos), while in pts treated with IRE-C only was 15 mos (6-22 mos) and 10.9 mos (range, 5-16 mos), respectively. The group treated with FOLFIRINOX-IRE-C showed median OS 22.5 mos (range, 15-36 mos) and median PFS 17.1 mos (range, 3-24 mos), while the group treated with AG-IRE-C had median OS 19 mos (range, 13-36 mos) and median PFS 15.8 mos (range, 7-24 mos). After IRE, 24 pts (71%) continued with adjuvant C, either FOLFIRINOX 5 pts (15%) or G-based regimen 18 pts (46%) until disease progression or unacceptable toxicity, while 12 pts (35%) have more than 24 mos OS and 3 pts (9%) have reached 36 mos OS and are still alive. Conclusions: The combination of C with IRE is safe and results in survival increase of LAPC pts. Pts treated with the sequence FOLFIRINOX-IRE-C seems to benefit the most.

Background: The ALPPS approach allows obtaining resectability of extensive hepatic malignancies by a rapid and large future liver remnant (FLR) hypertrophy. In several series, this treatment approach has been associated with high morbidity and mortality rates.

Background: To evaluate the safety of the Irreversible Electroporation (IRE) in patients diagnosed with unresectable pancreatic adenocarcinoma.

Background. FOLFIRINOX is an effective but toxic neoadjuvant chemotherapeutic protocol for patients with non-metastatic pancreatic ductal adenocarcinoma (PDAC). We present our institutional experience with FOLFIRINOX and surgical treatment for therapy patients with locally advanced and initially unresectable PDAC.

Background: Background: Liver metastases may be difficultly to manage by operative or ablative therapy. Isolated hepatic perfusion (IHP) and its alternative, Percutaneous Hepatic Perfusion (PHP), is a regional therapy which allows the delivery of high doses of chemotherapeutic agents and at the same time systemic toxicity is avoided. We conducted a systematic review of the literature in order to evaluate the efficacy of IHP or PHP on tumor response rates and overall survival. Methods: Methods: MEDLINE (1950 to 2011), EMBASE (1980 to 2011), and the Cochrane Library were searched to identify studies of outcomes in patients submitted to IHP or PHP for unresectable metastatic liver disease. Cohort studies that matched our inclusion criteria and reported the outcomes following the procedure were included. The MOOSE guidelines were used as a basis for this review. Results: Results: Sixteen studies met the inclusion criteria. Case-control studies resulted to conflicting results compared IHP with systemic chemotherapy regarded overall response rate and overall survival.Severe complications and especially hepatotoxicity where reported, which in some studies reached up to 65%. Although PHP resulted in less hepatotoxicity events, was associated with high rates of myelotoxicity. Conclusion: Conclusions: IHP has showed some encouraging Results, although the morbidity of the procedure is relatively high. Currently there is not enough good evidence that IHP better than systemic chemotherapy.

BackgroundPrimary pancreatic leiomyosarcoma is an extremely rare entity that needs high clinical suspicion in order to diagnose it at an early stage. Clinical characteristics, diagnosis, and management still remain challenging and controversial, especially in advanced stages, when tumor invades adjacent vessels and organs or gives distant metastases.Case presentationHerein, we describe a case of a 57-year-old woman suffering from advanced pancreatic leiomyosarcoma with thrombosis of the superior mesenteric vein, as well as liver lesions which were suspicious for metastasis. Multidisciplinary team decided for upfront chemotherapy to assess tumor response. Follow-up imaging after the completion of chemotherapy led tumor board to decide for subsequent surgical exploration. The patient underwent exploratory laparotomy and irreversible electroporation ablation of the pancreatic tumor. Postoperative course was uneventful, and she was discharged 10days later with a plan to receive adjuvant therapy. To the best of our knowledge, this is the first case of pancreatic leiomyosarcoma ever reported, treated with this novel technique of irreversible electroporation that could be an alternative and feasible way for the management of these rare malignancies.ConclusionsIn conclusion, primary pancreatic leiomyosarcoma is a rare and highly malignant tumor associated with poor prognosis. Nowadays, R0 surgical resection remains the cornerstone treatment, combined with adjuvant and/or neoadjuvant chemotherapy prior to resection. In the advanced setting, when major vessel invasion and distant metastases occur, chemotherapy along with irreversible electroporation ablation could be a helpful and possibly effective modality for the management of this highly aggressive tumor.

Background/Aim: Complete surgical excision, surgical knowledge and individualization of patient’s therapeutic approach in tertiary oncology centers and specialized surgical teams, result in improved outcomes.

Purpose: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) represents a revolutionary new surgical technique and one of the most promising advances in liver surgery over the last decade, which provides rapid and effective growth of liver remnant volume, allowing surgical resection of hepatic lesions initially considered unresectable. The aim of this review was to address from a critical point of view, the impact of this novel procedure conducted for primary liver malignancies, on tumor biology itself and thus on short and long-term outcomes, as disease free survival and overall survival. Methods: The present study was designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Identification of eligible studies was performed through a systematic search of the literature using Medline/PubMed, Scopus, Cochrane, Google Scholar, and clinicaltrials.gov databases. The end date of the literature search was set to 30th November 2018. The following keywords were used for the search: "Associating Liver Partition and Portal Vein Ligation for Staged hepatectomy", "ALPPS", "Portal Vein Embolization (PVE) And In Situ Split", "Portal Vein Ligation (PVL) And In Situ Split". Results: The 28 studies enrolled in the present analysis incorporated 136 patients who were subjected to ALPPS due to primary liver malignancy. R0 resection status has been documented in 20 studies estimated to be 97.24%. 30-day mortality was 9.55%. Concerning 30-day morbidity graded according to Clavien-Dindo classification, interestingly 7 studies stated no postoperative complications, neither minor (I-II) nor major (III-V). As for the oncological outcomes, median follow up was 10 months (range 0-36), recurrence rate was 36%, disease free survival ranged from 1 to 36 months with a median of 6 months and overall survival ranged from 1 to 36 months with a median of 11 months. Conclusions: ALPPS offers a reasonable chance of complete resection in patients with unresectable primary liver tumors. Optimal selection of patients, gaining the surgical experience of carrying out this technique and its impact on short and long-term results are issues that still remain under debate while waiting for the final outcomes of the multicenter registries with larger number of cases.

Background/Aim: Complete resection, surgical expertise and individualization of patient management in comprehensive oncology centres result in better clinical outcomes in patients presenting with retroperitoneal sarcomas. Patients and Methods: Clinical outcomes of primary and recurrent retroperitoneal sarcoma resections performed between January 2002 and December 2016 in two large surgical oncology, but non-sarcoma specialist centers, were reviewed to determine the efficacy of complete surgical resection as the principle instrument for treatment. The histological type, tumor size and grade, as well as organ resection, were recorded and subsequently reviewed. Results: Our study included 108 cases of sarcoma resection (60 first-time, 38 second-time and 10 third-time laparotomies) in 60 patients (35 males and 25 females). Most patients had complete resection: 57 had a macroscopically complete (R0/R1) resection and three had R2 resection. The 90-day mortality rate was zero and morbidity was minimal. Five-and 10-year overall survival (OS) rates were 88% and 79%, respectively, whereas the corresponding disease-free survival (DFS) rates were 65% and 59%, respectively. High-grade tumors were associated with decreased DFS (hazard ratio(HR)=3.35; 95% confidence interval(CI)=1.23-9.10; p=0.018) and decreased OS (HR=7.18; 95% CI=1.50-34.22; p=0.013). Conclusion: Complete surgical resection of retroperitoneal sarcomas combined with individualized patient management when offered by experienced surgical oncology teams, adhering to international guidelines, can succeed in providing patients with good long-term outcomes, comparable to those achieved at sarcoma-specialist centers.

Berger et al demonstrated that resection for retroperitoneal sarcomas (RPS) performed at academic cancer centers was an independent predictor of margin-negative resection (R0) but was not a statistically significant factor for survival. 1 Berger N.G. Silva J.P. Mogal H. et al. Overall survival after resection of retroperitoneal sarcoma at academic cancer centers versus community cancer centers: an analysis of the National Cancer Data Base. Surgery. 2017; https://doi.org/10.1016/j.surg.2017.07.009 Abstract Full Text Full Text PDF Scopus (27) Google Scholar These findings are of interest due to the increasing body of literature highlighting the role of center on sarcoma treatment outcomes.

Colorectal cancer is one of the leading causes of mortality in the Western world. Half of patients with colorectal cancer will develop liver-metastatic (CLM) disease, with fewer than 30% having surgically resectable disease at diagnosis. It is well established in the literature that major hepatectomy offers a high rate of R0 resection, however, with concommitant increased rates of mortality and morbidity. Emerging literature during the past two decades has demonstrated the potential superiority of parenchymal-sparing hepatectomy (PSH) in treating CLM disease in terms of oncological outcomes, survival and re-operation in cases of recurrence (salvageability). To date, no data regarding the evaluation of quality of life and cost after PSH have been published. PSH seems to be correlated with less mortality and morbidity, which can be translated in lower re-admission rates, better quality of life and, therefore, reduced relevant cost. Prospective studies and clinical trials evaluating the multiple beneficial role of a PSH surgical strategy in CLM disease are mandatory to support or reject the emerging belief that PSH could be the gold standard of treatment of CLM disease.

AIM:We reviewed our 20-year experience with non-Whipple operations (pancreas-preserving duodenectomy and transduodenal ampullectomy) for the treatment of benign, premalignant or early-stage malignant duodenal lesions.PATIENTS AND METHODS:Twenty-four patients who underwent non-Whipple operations between January 1996 and December 2015 were identified from an institutional database and retrospectively analyzed.RESULTS:Between 1996 and 2015, 10 patients underwent pancreas-preserving duodenectomy and 14 patients underwent transduodenal ampullectomy. The mean follow-up was 25.8 months (range=6-54 months) and no patient was lost to follow-up. Eighteen patients had preoperative diagnosis of duodenal adenomatosis, three patients had preoperative diagnosis of duodenal adenocarcinoma, one had a bleeding polyp and two had localized inflammation. Average operative time was 145 min (range=127-168 min) for transduodenal ampullectomy and 183 min (range=173-200 min) for pancreas-preserving duodenectomy (p<0.05). The estimated blood loss for transduodenal ampullectomy was 85 vs. 125 ml for pancreas-preserving duodenectomy (p<0.05). Early postoperative complications were noted in 13 cases (54.17%). There were no postoperative (90-day) deaths observed in this series and there were no recurrences during follow-up for the patients operated on with neoplastic lesions.CONCLUSION:For carefully selected patients, transduodenal ampullectomy and pancreas-preserving duodenectomy may be used in place of the Whipple operation for benign and occasionally early-stage malignant (Tis and T1) duodenal and ampullary disease.

Background/Aim: Diverticular disease is a first-class health care problem and one of the most common gastrointestinal disorders in western industrialized countries, causing significant morbidity and mortality. In this review of the literature, we aim to assess the feasibility and effectiveness of the laparoscopic approach in both elective and emergency setting of diverticular disease. Materials and Methods: A bibliographic search of articles was performed using the electronic database Medline from PubMed. Of 341 articles identified, 279 were excluded, resulting in 62 full-text articles for review. Our final review included 16 articles. Results: The 16 articles included in the final review consisted of 6 retrospective studies, 5 prospective studies, 2 randomized controlled trials, 1 systematic review and meta-analysis, and 2 systematic reviews. Seven articles considered elective laparoscopic sigmoid resection, 7 articles evaluated laparoscopic peritoneal lavage, and 2 articles considered emergency laparoscopic sigmoid resection for perforated diverticulitis. The elective laparoscopic approach is feasible and safe. Laparoscopic peritoneal lavage has emerged as a safe and effective minimally invasive procedure for the treatment of perforated diverticulitis. Furthermore, in selected patients, emergency laparoscopic sigmoidectomy could also be feasible for perforated diverticulitis with generalized peritonitis. Conclusions: Laparoscopic approach can be a safe and effective option in both elective and emergency setting of diverticular disease. Large, prospective, randomized studies should be conducted to confirm these findings.