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Simple Summary: With ageing, the number of pancreaticoduodenectomies (PD) for benign or malignant disease is expected to increase in elderly patients. The aim of the present meta-analysis is to compare the surgical outcomes of MIPD in elderly versus younger patients. The results of our analysis disclose no considerable differences in terms of technical and post-operative outcomes between the two groups. However, slightly higher, but acceptable, major complication and mortality rates were recorded in the elderly cohort. Although the real additional value of minimally invasive surgery in this frailty subset of patients needs to be further investigated, our findings reveal that MIPD seems to be relatively safe and feasible in elderly patients. (1) Background: With ageing, the number of pancreaticoduodenectomies (PD) for benign or malignant disease is expected to increase in elderly patients. However, whether minimally invasive pancreaticoduodenectomy (MIPD) should be performed in the elderly is not clear yet and it is still debated. (2) Materials and Methods: A systematic review and meta-analysis was conducted including seven published articles comparing the technical and post-operative outcomes of MIPD in elderly versus younger patients up to December 2022. (3) Results: In total, 1378 patients were included in the meta-analysis. In term of overall and Clavien–Dindo I/II complication rates, post-operative pancreatic fistula (POPF) grade > A rates and biliary leakage, abdominal collection, post-operative bleeding and delayed gastric emptying rates, no differences emerged between the two groups. However, this study showed slightly higher intraoperative blood loss [MD 43.41, (95%CI 14.45, 72.38) p = 0.003], Clavien–Dindo ≥ III complication rates [OR 1.87, (95%CI 1.13, 3.11) p = 0.02] and mortality rates [OR 2.61, (95%CI 1.20, 5.68) p = 0.02] in the elderly compared with the younger group. Interestingly, as a minor endpoint, no differences in terms of the mean number of harvested lymphnode and of R0 resection rates were found. (4) Conclusion: MIPD seems to be relatively safe; however, there are slightly higher major morbidity, lung complication and mortality rates in elderly patients, who potentially represent the individuals that may benefit the most from the minimally invasive approach. [ABSTRACT FROM AUTHOR]

Background. Pancreatic trauma is an uncommon injury that occurs usually in a young population and is frequently overlooked and not readily appreciated on initial examination. Nowadays, the diagnosis and management of pancreatic trauma are still controversial, and there is no gold standard for the treatment. The aim of this study is to describe our experience in the management of blunt pancreatic trauma with a laparoscopic approach and review the literature on laparoscopic management of pancreatic trauma. Methods. A systematic literature review was performed, and 40 cases were reported and analysed; 10 cases were excluded because the complete data were not retrievable. We also reported our experience with the case of an 18-year-old male diagnosed with a deep laceration of the pancreas between body and tail, involving the main pancreatic duct, and with a concomitant hematoma. The patient underwent exploratory laparoscopy with abdominal toilet, necrosectomy, and suture of main pancreatic duct; the total blood loss was less than 200 ml, and the total operative time was 180 minutes. The patient recovered uneventfully and was discharged on the 6th postoperative day. Results. 30 patients with pancreatic trauma, 10 adults and 20 pediatrics (mean age 28.2 years and 10.5 years), underwent a total laparoscopic approach: 2 distal pancreatic-splenectomy, 22 spleen-preserving distal pancreatectomy, and 6 laparoscopic drainage. The mean operative time for the adult and pediatric populations was 160.6 and 214.5 minutes, the mean estimated blood loss was 400 ml and 75 ml, and the mean hospital stay was 14.9 and 9 days, respectively. Conclusion. Laparoscopic management for pancreatic trauma can be considered feasible and safe when performed by an experienced laparoscopic pancreatic team, and in such a setting, it can be considered a viable alternative to open surgery, offering the well-known benefits of minimally invasive surgery. [ABSTRACT FROM AUTHOR]

Background: Pancreatic surgery has been associated with important postoperative morbidity, mortality and prolonged length of hospital stay. In pancreatic surgery, the effect of poor preoperative nutritional status and muscle wasting on postsurgery clinical outcomes still remains unclear and controversial. Materials and Methods: A total of 103 consecutive patients with histologically proven carcinoma undergoing elective pancreatic surgery from June 2015 through to July 2020 were included and retrospectively studied. A multidimensional nutritional assessment was performed before elective surgery as required by the local clinical pathway. Clinical and nutritional data were collected in a medical database at diagnosis and after surgery. Results: In the multivariable analysis, body mass index (OR 1.25, 95% CI 1.04–1.59, p = 0.039) and weight loss (OR 1.16, 95% CI 1.06–1.29, p = 0.004) were associated with Clavien score I–II; weight loss (OR 1.13, 95% CI 1.02–1.27, p = 0.027) affected postsurgery morbidity/mortality, and reduced muscle mass was identified as an independent, prognostic factor for postsurgery digestive hemorrhages (OR 0.10, 95% CI 0.01 0.72, p = 0.03) and Clavien score I–II (OR 7.43, 95% CI 1.53–44.88, p = 0.018). No association was identified between nutritional status parameters before surgery and length of hospital stay, 30 days reintervention, 30 days readmission, pancreatic fistula, biliary fistula, Clavien score III–IV, Clavien score V and delayed gastric emptying. Conclusions: An impaired nutritional status before pancreatic surgery affects many postoperative outcomes. Assessment of nutritional status should be part of routine preoperative procedures in order to achieve early and appropriate nutritional support in pancreatic cancer patients. Further studies are needed to better understand the effect of preoperative nutritional therapy on short-term clinical outcomes in patients undergoing pancreatic elective surgery. [ABSTRACT FROM AUTHOR]

Simple Summary: Primary liver transplantation (PLT) for HCC represents the ideal treatment. However, since organ shortage increases the risk of drop-out from the waiting list for tumor progression, a new surgical strategy has been developed: Salvage Liver Transplantation (SLT) can be offered as an additional curative strategy for HCC recurrence after liver resection. The aim of this updated meta-analysis is to compare surgical and long-term outcomes of SLT versus PLT for HCC. The findings of our analysis reveal that SLT offers comparable surgical outcomes but slightly poorer oncological long-term outcomes with respect to PLT. (1) Background: Primary liver transplantation (PLT) for HCC represents the ideal treatment. However, since organ shortage increases the risk of drop-out from the waiting list for tumor progression, a new surgical strategy has been developed: Salvage Liver Transplantation (SLT) can be offered as an additional curative strategy for HCC recurrence after liver resection. The aim of this updated meta-analysis is to compare surgical and long-term outcomes of SLT versus PLT for HCC. (2) Materials and Methods: A systematic review and meta-analysis was conducted using the published papers comparing SLT and PLT up to January 2022. (3) Results: 25 studies describing 11,275 patients met the inclusion criteria. The meta-analysis revealed no statistical difference in intraoperative blood loss, overall vascular complications, retransplantation rate, and hospital stay in the SLT group compared with the PLT group. However, the SLT group showed a slightly significant lower 5-year OS rate and 5-year disease-free survival rate. (4) Conclusion: meta-analysis advocates the relative safety and feasibility of both Salvage LT and Primary LT strategies. Specifically, SLT seems to have comparable surgical outcomes but slightly poorer long-term survival than PLT. [ABSTRACT FROM AUTHOR]

Background: Pancreatic surgery is still a challenge even in high‐volume centers. Clinically relevant postoperative pancreatic fistula (CR‐POPF) represents the greatest contributor to major morbidity and mortality, especially following pancreatic distal resection. In this study, we compared robotic distal pancreatectomy (RDP) to open distal pancreatectomy (ODP) in terms of CR‐POPF development and analyzed oncologic efficacy of RDP in the subgroup of patients with pancreatic ductal adenocarcinoma (PDAC). Methods: We collected data from five high‐volume centers for pancreatic surgery and performed a matched comparison analysis to compare short and long‐term outcomes after ODP or RDP. Patients were matched with a 2:1 ratio according to age, ASA (American Society of Anesthesiologists) score, body mass index (BMI), final pathology, and TNM (Tumour, Node, Metastasis) staging system VIII ed. Results: Two hundred and forty‐six patients who underwent 82 RDPs and 164 ODPs were included. No differences were found in the incidence of CR‐POPF. In the PDAC group, median DFS and OS were 10.8 months and 14.8 months in the ODP group and 10.4 months and 15 months in the RDP group, respectively. Conclusions: Robotic distal pancreatectomy is a safe surgical strategy for PDAC and incidence of CR‐POPF is equivalent between RDP and ODP. RDP should be considered equivalent to ODP in terms of oncological efficacy when performed in high‐volume and proficient centers. [ABSTRACT FROM AUTHOR]

Background. While laparoscopy is currently adopted for hepatic resections, robotic approaches to the liver have not gained wide acceptance. We decided to analyze the learning curve in the field of robotic liver surgery comparing short-term outcomes between the first and the second half of our series. Methods. We retrospectively reviewed demographics and clinical data of patients who underwent robotic liver resection at our institution from July 2014 through September 2017. 60 patients diagnosed with primary or secondary liver neoplasms or hydatid disease were included in this study. ASA PS >3, heart failure, respiratory insufficiency, and general contraindication to pneumoperitoneum were exclusion criteria. Results. 60 patients were included. We observed a statistically significant decrease in operative time (p<0.001), intraoperative blood loss (p=0.01), and postoperative complications (p<0.001) after 30 cases. From the interpretation of the CUSUM curve, the time of operation appears to be significantly reduced after the first 30 operations. Discussion. This is the first European analysis of the learning curve for robotic liver resection in an HPB and liver transplant referral center. However, more studies are needed to confirm such results outside a HPB referral center. This is crucial to develop formal credentialing protocols for both junior and senior surgeons. [ABSTRACT FROM AUTHOR]

Background: Pancreatic neuroendocrine tumors (PanNETs) are relatively rare neoplasms with a low to mild malignant potential. They can be further divided into functioning and nonfunctioning, according to their secretive activity. Surgery is an optimal approach, but the classic open approach is challenging, with some patients having long hospitalization and potentially life-threatening complications. The robotic approach for PanNETs may represent an option to optimize their management.Methods: We retrospectively reviewed our prospectively maintained databases from 2 high-volume Italian centers for pancreatic surgery. Demographics, pathological characteristics, perioperative outcome, and medium-term follow-up of patients who underwent robotic pancreatic enucleations were collected.Results: Twelve patients with final diagnosis of PanNET were included. The mean age of the patients was 53.8 years (25-77). The median body mass index was 26 (24-29). Three lesions were functioning insulinomas, while the others were nonfunctioning tumors. No deaths occurred. Mild postoperative complications occurred, except for 1 grade B pancreatic fistula. The mean postoperative stay was 3.9 days (2-5).Conclusions: Our results confirm that robotic enucleation is a feasible and safe approach for the treatment of PanNETs, with short hospital stay and low incidence of morbidity. [ABSTRACT FROM AUTHOR]

Background. In the context of cirrhosis, portal vein thrombosis (PVT) is present in 2.1% to 26% of patients. PVTis no longer considered an absolute contraindication for liver transplantation, and nowadays, surgical strategies depend on the extent of PVT. Complete PVTis associated with higher morbidity rates and poor prognosis, while comparable long-term outcomes can be achieved as long as physiological portal in8ow is restored. Materials and Methods. We report our experience with a 45-year-old patient undergoing liver transplant with a PVT (stage III-b). To restore portal vein in8ow to the liver, an extra-anatomic jump graft from the right colic vein with donor iliac vein interposition was constructed. Results. The patient recovered well, with a progressive improvement of the general conditions, and was finally discharged on p.o.d. 14. No anastomotic defects were found at the postoperative CTscan 10 months after the surgery. Conclusion. Our technical innovation represents a valid and safe alternative to the cavoportal hemitransposition, providing a proper 8ow restoration and reproducing a physiological setting, while avoiding the complications related to the cavoportal shunt. We believe that the reconstitution of liver portal in8ow should be obtained with the most physiological approach possible and considering long-term liver function. [ABSTRACT FROM AUTHOR]

Background: We hypothesized that frailty acts as a measure of health outcomes in the context of LT. The aim of this study was to explore frailty index across LT, as a measure of morbidity and mortality. This was a retrospective observational study including all consecutive 47 HIV+patients who received LT in Modena, Italy from 2003 to June 2015. Methods: frailty index (FI) was constructed from 30 health variables. It was used both as a continuous score and as a categorical variable, defning 'most frail' a FI > 0.45. FI change across transplant (deltaFI, ΔFI) was calculated as the diference between year 1 FI (FI-Y1) and pre-transplant FI (FI-t0). The outcomes measures were mortality and "otpimal LT" (defned as being alive without multi-morbidity). Results: Median value of FI-t0 was 0.48 (IQR 0.42-0.52), FI-Y1 was 0.31 (IQR 0.26-0.41). At year fve mortality rate was 45%, "optimal transplant" rate at year 1 was 38%. All the patients who died in the post-LT were most frail in the pre-LT. ΔFI was a predictor of mortality after correction for age and MELD (HR = 1.10, p = 0.006) and was inversely associated with optimal transplant after correction for age (HR = 1.04, p = 0.01). Conclusions: We validated FI as a valuable health measure in HIV transplant. In particular, we found a relevant correlation between FI strata at baseline and mortality and a statistically significant correlation between, ΔFI and survival rate. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic liver resection (LLR) is now widely adopted for the treatment of liver malignancies. Liver resection with laparoscopic approach was first adopted for tumors located in the peripheral portion of the anterolateral segments of the liver, but recent experiences in literature modified the attitude toward that approach. We herein report our technique and outcomes of LLR for hepatocellular carcinoma (HCC) located in the right-posterior segments of the liver (VI and VII).Materials and Methods: We retrospectively reviewed our prospectively maintained database, comparing peri- and postoperative outcomes of patients who underwent laparoscopic (13 patients) or open (51 patients) resections for HCC localized in the right-posterior segments between 2000 and 2014.Results: The two populations were homogeneous, showing no statistically significant differences in terms of gender, age, body mass index, and cirrhosis prevalence. Alpha-fetoprotein levels were higher in the open group (P = .04) and etiology of cirrhosis varied in a statistically significant manner (P = .01). The laparoscopic group showed an improved perioperative outcome with statistically significant less postoperative morbidity (P = .01) and less in-hospital stay (P = .0001). No differences were found in terms of blood loss or operative time, but any Pringle maneuver was needed (P = .04).Conclusions: Patients affected by HCC localized in the right-posterior segments of the liver can be safely treated with laparoscopic approach. However, this kind of procedure can be challenging and should be performed in tertiary referral hospitals to provide the patient the best care, with the integration of different specialties. [ABSTRACT FROM AUTHOR]