Hepatobiliary Surgery Unit

Ospedale San Raffaele

key figures 

CLINICAL SERVICES:

  • Treatment of acute and chronic liver disease
  • Treatment of benign and malignant diseases of the Liver
  • Treatment of Lymphedema
  • Treatment of biliary tract diseases

PROCEDURES PERFORMED PER YEAR:

  • 300 Hepatic resections performed
  • Mean number of liver resections per year (2004-2017): 188
    • Open approach: 1837
    • Laparoscopic approach: 777
  • Number of laparoscopic resections (2005-2017): 777 (29.7% of the institutional series)

Clinical and research activities are dedicated to improve both diagnosis and treatment for hepatobiliary diseases, with a particular commitment to oncological patients, affected by benign and malignant tumours.

The Hepatobiliary Surgery Unit is dedicated to the treatment of malignant and benign liver diseases of surgical interest, with a specific focus on primary tumour pathology (such as hepatocellular carcinoma, cholangiocarcinoma, rare neoplasia) and secondary tumour pathology (hepatic metastases coming from colorectal neoplasia, neuroendocrine tumour or non-colorectal neuroendocrine neoplasia) of the liver and the biliary tract.

More than ever before, liver surgery needs high-level, specific knowledge and expertise, both to exploit the most recent improvements in surgery techniques and technologies as well as to address properly the complexity of liver tumour pathology.

For this reason, at the San Raffaele Hospital there is a Hepatobiliary Surgery Unit exclusively dedicated – since more than a decade – to liver surgery, where over 2.500 hepatic resections have been performed, including all types of conventional hepatic resections, as well as specific programs for extensive resections and mini-resections with a non-invasive laparoscopy technique.

The program of Mini-Invasive Liver Surgery has been active for over 15 years, making the Hepatobiliary Surgery a national and international recognized leader in this field. The volume of the surgical activity is modulated on the number of patients, so that waiting times are limited and adequate to the severity of the diagnosis and the consequent need for a prompt, efficient, and effective treatment.

A multidisciplinary team (a hepatic surgeon, an oncologist, a medical hepatologist, an interventional radiologist and a radiotherapist) defines the diagnostic-therapeutic procedure for each patient during a specific weekly meeting (MMEB - Multidisciplinary Hepatobiliary Meeting). This multidisciplinary approach is fundamental, especially in some peculiar situations, such as perilary tumours. Thanks to this approach, the Hepatobiliary Surgery Unit of the San Raffaele Hospital has been able to constantly optimize the oncological results, mitigating surgery risks.

We take care of patients as a whole: part of our staff is a medical hepatologist, a choice that overcomes the traditional separation between surgeons and internist doctors, essential for optimizing the diagnosis and treatment. Regardless of the stage of the disease and the therapeutic needs, these two professional figures collaborate within the same Unit, intervening in the different phases of treatment.

As shown in Table 2, Between January 2004 and January 2018, 2614 liver resections were performed at the Hepatobiliary Surgery Unit of the San Raffaele Hospital. Open and laparoscopic approaches were used in 1837 and 777 cases, respectively. Details regarding open procedures are shown in Figure 1, below. In particular, 171 patients had an inadequate volume of the remnant liver at the moment of diagnosis and therefore required procedures to induce hypertrophy of the liver remnant (Portal vein embolization/ligation, two stage hepatectomy, ALPPS procedures).

Details regarding laparoscopic liver resections are provided in Figure 2, below. The number of laparoscopic resections has progressively increased from 2005 (when it constituted 5.8% of the whole series of liver resections) to 2017 (now it constitutes 67.1% of the whole activity).

treatmentS

Laparoscopic Liver Resection

The laparoscopic approach to liver surgery has been recently introduced into clinical practice and has not yet reached the diffusion and standardization to other areas of general surgery due to its specific characteristics (technical difficulties in mobilization and transection of the liver, intraoperative bleeding complications). Nevertheless, a recent Consensus Conference held in Southampton in 20171 affirmed the advantages of laparoscopic surgery compared to open surgery in terms of intraoperative blood loss, postoperative hospitalization, overall morbidity. Initial studies also suggest its cost effectiveness2. In this context, the San Raffaele Hepatobiliary Surgery Unit plays an important role in national and international settings. The elements that characterize this leadership include:

  1. Development of an original liver transection technique3, and the first application to liver resection of a technique that further develops mini-invasiveness (single port technique4
  2. Development of the first prospective comparative clinical trials showing the advantage of the laparoscopic approach in terms of postoperative pain and length of stay5
  3. First systematic review showing the advantages of the laparoscopic approach6  
  4. Inclusion of the institutional series in the first world systematic review7  
  5. Production of scientific papers (period 2008-2010) which were subsequently selected and used for international meta-analyses that demonstrated general advantages of the laparoscopic approach8  and specific advantages for HCC surgery9
  6. Dr. Aldrighetti was the coordinator and analysed data of the first National Survey regarding minimally invasive liver surgery (2012) which collected data from 1497 procedures performed in 39 Italian centers
  7. Dr. Aldrighetti was a member of the expert panel during the 2nd International Consensus Conference on Laparoscopic Liver Surgery, held Morioka, Japan in 201410   and during the 1st European Guidelines Meeting on Laparoscopic Liver Surgery, held in Southampton, UK in 201711   – in particular he was the team leader of the group analysing the topic of technical aspects in laparoscopic major hepatectomies
  8. Dr. Aldrighetti is the coordinator of the Italian Registry of the Italian Group of Minimally Invasive Liver surgery (I Go MILS) and of the Italian School of Minimally invasive liver surgery

Perihilar tumours

Diagnosis and treatment of perihilar cholangiocarcinoma require a multidisciplinary approach with the synergistic intervention of surgeons, gastroenterologists, radiologists, oncologists and radiotherapists, but preoperative management and patient preparation have not yet reached the diffusion and standardization of other areas of general surgery due to specific disease characteristics (need for major liver resections and inadequate volume of remnant, need for management of preoperative jaundice). At the San Raffaele Hepatobiliary Surgery Unit specialized skills cooperate in order to standardize and optimize the treatment of this disease while maintaining the philosophy of a "patient-tailored therapy".

The San Raffaele Hepatobiliary Surgery Unit plays an important role on a national and international scale, due to the following reasons:

  1. First prospective clinical trials in Western countries12
  2. Production of clinical trials subsequently selected for international reviews showing general advantages of surgery13  and specific advantages of multidisciplinary management in tertiary referral centers14
  3. The series presently consist of 194 procedures of liver and biliary resections, constituting the largest Italian series and being among the ones with the widest Western experiences  

ALPPS approach

The ALPPS (Associating Liver Partitioning and Portal Vein Ligation for Staged Hepatectomy) is a procedure recently introduced in hepatobiliary surgery15  which consists in the association, during the first surgical procedure, of the ligature of the right portal vein with the transection of the liver parenchyma in order to induce an increased rate of liver hypertrophy (FLR, Future Liver Remnant) in a shorter time interval (7-10 days) compared to standard techniques ( Portal Vein Embolization, Two Stage Hepatectomy). ALPPS has been designated for the treatment of advanced hepatic cancer in patients with insufficiency of remnant liver. In this context, the San Raffaele Hepatobiliary Surgery Unit plays an important role on a national and international level. The elements that characterize this leadership include:

  1. The series presently consists of 32 procedures of ALPPS, constitutes the largest Italian series and is among the largest experience internationally  
  2. Contribution to scientific literature by completing of one of the first trials regarding indications to ALPPS approach16, inclusion of the institutional series in the first systematic review regarding ALPPS17, and creation of the first comparative study between ALPPS and Two Stage Hepatectomy18 
  3. Inclusion of data from the institutional series in the International ALPPS Registry19  and the Italian ALPPS Registry20   
  4. Dr. Aldrighetti was a member of the expert panel during the “1st International Consensus Conference on ALPPS” held in Hamburg, Germany, to define international guidelines regarding ALPPS. He was the team leader of the group “Colorectal Liver Metastases and aspects of Chemotherapy”

Research projects and fields of implementation

  1. Physiology and prevention of postoperative liver failure, in particular “small for size syndrome”. Physiology and clinical induction of liver regeneration
  2. Profiling, immune response and prognostic biomarkers of primary and secondary liver tumours
  3. Physiology and prevention of ischemia-reperfusion injury
  4. Mini-invasive techniques in liver surgery
  5. Fast track programs in liver surgery
  6. Liver Regeneration

 

NOTABLE ADVANCED TECHNOLOGICAL EQUIPMENT

Modern operating room equipped with advanced open and laparoscopic instrumentation to perform all liver and biliary procedures, including those with high degree of technical complexity.

Instrumentation includes:

  • Ultrasonic dissector (Sonosurg),
  • energy devices for dissection (Thunderbeat, Olympus and Harmonic, Ethicon)
  • Intraoperative ultrasound
    • Hitachi Medical System - AriettaV70: Multi-Layered and Single Crystal technologies allow more efficient transmission and reception of the ultrasound pulse with minimal energy loss, increasing both the sensitivity and clarity of the images
    • New front-end technology: The Compound Pulsed Wave Generator (CPWG+) uses an efficient programmable transmission waveform to generate pulses with high sensitivity and resolution
    • PIXEL Focusing for increased precision and clear delineation of the region of interest;
    • The ultrasound-specific high-performance processor, Ultra Backend, performs powerful processing such as HI-REZ+;
    • With a high contrast ratio and wide viewing angle, the IPS-Pro monitor gives a rich representation of the displayed image
  • Laparoscopic vision is accomplished by 4K technology, the new surgical endoscopy system incorporating Ultra High Definition, Wider Color Gamut, and Magnified Visualization as key concept, in order to achieve improved visibility and further support the accuracy and safety of laparoscopic surgery

 

Additional Information

Volume of production:

  • 573 publications
  • 261 articles "in exstenso" on national and international journals and proceedings
  • 312 abstracts during national and international meetings

Impact Factor:

  • 184 in journals with Impact Factor
  • Cumulative Impact Factor (JCR 2014) 577,01
  • Mean Impact Factor 3.41.

H-index of Dr. Aldrighetti is 39 according to Scopus and 36 according to Web of Sciences

 

NoteS

1Abu Hilal, Aldrighetti et al, Ann Surg, 2017
2Abu Hilal, Surg Endoscopy, 2013
3Aldrighetti et al, The American Journal of Surgery 2008; 195: 270–272
4Aldrighetti et al, Surg. Endoscopy 2012; 26: 2016-2022
5Aldrighetti et al, J. Gastrointest. Surg. 2008; 12: 457-462
6Aldrighetti, Nature Clin. Pract. Gastroenterol Hepatol. 2008; 5:648-654
7Nguyen, Ann Surg, 2008
8Mirnezami, HPB, 2013
9Zhou, Dig Dis Sci, 2013
10Wakabayashi G et al. Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka. Ann Surg 2015
11Guidelines published in Ann Surg, 2017
12Aldrighetti et al, World J Surg. 2013 Jun;37(6):1388-96; Aldrighetti et al, J Gastrointest Surg. 2015 Jul;19(7):1324-33
13Ruys, HPB. 2014
14Gomez, EJSO. 2014
15De Santibanes, World J Surg 2011 ; Schnitzbauer, Ann Surg 2012
16Ratti et al, Updates Surg 2014
17Schadde et al; Ann Surg Oncol 2014
18Ratti et al, Ann Surg Oncol 2015
19Schadde E, Ardiles V, Robles-Campos R, Malago M, Machado M, Hernandez-Alejandro R, Soubrane O, Schnitzbauer A, Raptis D, Tschuor C, Petrowsky H, De Santibanes E, Clavien PA, on behalf of the ALPPS Registry Group. Early survival and safety of ALPPS: First Report of the International ALPPS Registry. Ann Surg. 2014
20«Importance of primary indication and liver function between stages: results of a multicentre Italian audit of ALPPS 2012-2014 » HPB, 2016