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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 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. 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: Pancreatic texture is one of the key predictors of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). Currently, the 'gold standard' for assessment of pancreatic texture is surgeon's subjective evaluation through manual palpation. Aim: To evaluate a new 'durometer' that is able to assess quantitatively the pancreatic stiffness by measuring its elastic module (i.e., the resistance offered by the pancreatic stump when elastically deformed expressed in mPa). Methods: Measurements were obtained from the pancreatic remnant during 138 consecutive PDs performed at the Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust. Values were correlated to clinical features and, in particular, with the senior surgeon's evaluation of pancreatic texture (hard/soft). Sixteen beating-heart donors were used as a control group to assess the stiffness of a non-pathologic pancreas. Univariate analysis was performed for the assessment of POPF predictors. Results: Durometry allowed segregating between non-pathologic, soft and hard pancreas according to surgeon's evaluation (mean values 111 vs. 196 vs. 366 mPa, p < 0.01). There were no significant differences in stiffness with regard to histology, BMI, and neoadjuvant therapy. Larger tumors (>20 mm) and male sex were associated with greater stiffness on univariate analysis. Pancreatic texture, pancreatic duct size, BMI, prior neoadjuvant therapy, and histology were predictors of POPF. Patients who developed POPF showed a lesser stiffness (178 vs. 261 mPa, p = 0.05). Conclusion: Assessment of pancreatic stiffness using a durometer correlated with the surgeon's evaluation of pancreatic texture. Measurement of pancreatic parenchymal stiffness is reliable and correlates with the development of POPF. [ABSTRACT FROM AUTHOR]

Background & Aims Salvage liver transplantation ( SLT) is an attractive sequential strategy which combines liver resection ( LR) for hepatocellular carcinoma ( HCC), followed by liver transplant ( LT) in the event of HCC recurrence or progressive liver deterioration. To compare the long-term results of SLT with primary liver transplant ( PLT). Methods Between 2000 and 2011, 125 patients (72 transplantable) underwent LR and 226 underwent LT in our unit. The outcome of SLT was analysed in a two-step fashion: firstly, SLT ( n = 28) was compared with PLT ( n = 198), secondly an intention-to-treat analysis was performed on all transplantable HCC patients who underwent LR ( LRT group = 72) compared to PLT ( n = 198). Results The five-year overall survival ( OS) was 65.4% vs. 49.2% ( P = 0.63), and disease-free survival ( DFS) was 89.7% vs. 80.6% ( P = 0.31) for PLT and SLT respectively. Predictive factors for DFS after LT included HCC total diameter [hazard ratio (HR) 1.29 P = 0.003], alpha-foetoprotein (HR 1.002 P < 0.001) and number of HCC nodules (HR 1.317 P = 0.035), whereas viral hepatitis C positivity (HR 1.911 P = 0.03) and outside Up-to-seven criteria (HR 2.652 P < 0.001) were negative independent prediction factors of OS. Intention-to-treat analysis showed that OS at 5 years was improved in PLT vs. LRT ( LRT n = 72 including SLT plus LR group) and was 69.4% vs. 42.2% ( P < 0.004), with an additional increase in DFS (89.2% vs. 54.5% respectively P < 0.001). Conclusion Salvage liver transplantation is a safe treatment strategy, as it does not impair long-term survival. At intention-to-treat analysis, PLT showed improved survival compared with LRT. [ABSTRACT FROM AUTHOR]

Objectives To assess the safety and long-term results of hepatic resection of colorectal liver metastases ( CLM) in older adults. Design Case-control. Setting Single liver and multivisceral transplant center. Participants Individuals with CLM: 32 aged 70 and older (older group) and 32 younger than 70 (younger group) matched in a 1:1 ratio according to sex, primary tumor site, liver metastases at diagnosis, number of metastases, maximum tumor size, infiltration of cut margin, type of hepatic resection, and hepatic resection timing. Measurements Postoperative complications and survival rates. Results There was no significant difference in preoperative clinical findings between the two study groups. The incidence of cumulative postoperative complications was similar in the older (28.1%) and younger (34.4%) groups ( P = .10). One-, 3-, and 5-year disease-free survival rates were 57.6%, 32.9%, and 16.4%, respectively, in the younger group and 67.9%, 29.2%, and 19.5%, respectively, in the older group ( P = .72). One-, 3-, and 5-year participant survival rates were 84.1%, 51.9%, and 33.3%, respectively, in the older group and 93.6%, 63%, and 28%, respectively, in the younger group ( P = .50). Conclusions Resection of colorectal liver metastases in older adults can be performed with low mortality and morbidity and offers a long-time survival advantage to many of these individuals. Based on the results of this case-control study, older adults should be considered for surgical treatment whenever possible. [ABSTRACT FROM AUTHOR]

Montalti R, Busani S, Masetti M, Girardis M, Di Benedetto F, Begliomini B, Rompianesi G, Rinaldi L, Ballarin R, Pasetto A, Gerunda GE. Two-stage liver transplantation: an effective procedure in urgent conditions. Clin Transplant 2010: 24: 122–126. © 2009 John Wiley & Sons A/S. Temporary portocaval shunt and total hepatectomy is a technique used in the presence of toxic liver syndrome because of fulminant hepatic failure, hepatic trauma, primary non-function (PNF), and eclampsia. We performed this technique on four patients. An indication for anhepatic state was severe hemodynamic instability in three of them. Etiologies of these three patients were as follows: PNF after liver transplantation, ischemic hepatitis after right hepatic artery embolization, and massive reperfusion syndrome during a liver transplantation. In the fourth patient, during the liver transplantation when hepatic artery was ligated, a kidney carcinoma in the donor graft was discovered. We decided to complete the hepatectomy and to construct a temporary portocaval shunt. Mean anhepatic phases were 19 h and 15 min. All patients survived the two-stage liver transplantation procedure without major complications. Our cases demonstrated that temporary portocaval shunt while awaiting urgent liver transplantation could be an effective “bridge” in selected patients who develop toxic liver syndrome; however, a short time between portocaval shunt and transplantation and careful intensive care managements are mandatory. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which is concerned with liver transplantation in older adults.

A letter to the editor is presented concerning the use of donated livers from very old organ donors in liver transplants.

A letter to the editor about pancreatic resections for malignancy in an older patient is presented.