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Anaesthetic perioperative management of patients with pancreatic cancer

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World Journal of Gastroenterology 2014年第9期20卷 2304-2320页

作者： Lesley De Pietri roberto montalti Bruno Begliomini Division of Anaesthesiology and Intensive Care Unit Azienda Ospedaliero-Universitaria di Modena-Policlinico 41100 Modena Italy Transplantation Surgery Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona 60126 Modena Italy

Pancreatic cancer remains a significant and unresolved therapeutic ***,the only curative treatment for pancreatic cancer is surgical *** surgery represents a technically demanding major abdominal procedure that can occasionally lead to a number of pathophysiological alterations resulting in increased morbidity and ***,rather than surgical complications,cause the majority of *** patients are increasingly referred to surgery with at advanced ages and because pancreatic surgery is extremely complex,anaesthesiologists and surgeons play a crucial role in preoperative evaluations and diagnoses for surgical *** anaesthetist plays a key role in perioperative management and can significantly influence patient *** optimise overall care,patients should be appropriately referred to tertiary centres,where multidisciplinary teams(surgical,medical,radiation oncologists,gastroenterologists,interventional radiologists and anaesthetists)work together and where close cooperation between surgeons and anaesthesiologists promotes the safe performance of major gastrointestinal surgeries with acceptable morbidity and mortality *** this review,we sought to provide simple daily recommendations to the clinicians who manage pancreatic surgery patients to make their work easier and suggest a joint approach between surgeons and anaesthesiologists in daily decision making.

关键词： Pancreatic cancer Pancreatic surgery Perioperative anaesthesia management

Artificial intelligence in the diagnosis and management of colorectal cancer liver metastases

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World Journal of Gastroenterology 2022年第1期28卷 108-122页

作者： Gianluca Rompianesi Francesca Pegoraro Carlo DL Ceresa roberto montalti roberto Ivan Troisi Division of Hepato-Bilio-Pancreatic Minimally Invasive and Robotic SurgeryDepartment of Clinical Medicine and SurgeryFederico II University HospitalNaples 80125Italy Department of Hepato-Pancreato-Biliary Surgery Oxford University Hospitals NHS Foundation TrustOxford OX39ESUnited Kingdom Division of Hepato-Bilio-Pancreatic Minimally Invasive and Robotic SurgeryDepartment of Public HealthFederico II University HospitalNaples 80125Italy

Colorectal cancer(CRC)is the third most common malignancy worldwide,with approximately 50%of patients developing colorectal cancer liver metastasis(CRLM)during the follow-up *** of CRLM is best achieved via a multidisciplinary approach and the diagnostic and therapeutic decision-making process is *** order to optimize patients’survival and quality of life,there are several unsolved challenges which must be *** primarily include a timely diagnosis and the identification of reliable prognostic ***,to allow optimal treatment options,a precision-medicine,personalized approach is *** widespread digitalization of healthcare generates a vast amount of data and together with accessible high-performance computing,artificial intelligence(AI)technologies can be *** increasing diagnostic accuracy,reducing timings and costs,the application of AI could help mitigate the current shortcomings in CRLM *** this review we explore the available evidence of the possible role of AI in all phases of the CRLM natural *** analysis and convolutional neural networks(CNN)which combine computed tomography(CT)images with clinical data have been developed to predict CRLM development in CRC *** models have also proven themselves to perform similarly or better than expert radiologists in detecting CRLM on CT and magnetic resonance scans or identifying them from the noninvasive analysis of patients’exhaled *** application of AI and machine learning(ML)in diagnosing CRLM has also been extended to histopathological examination in order to rapidly and accurately identify CRLM tissue and its different histopathological growth *** and CNN have shown good accuracy in predicting response to chemotherapy,early local tumor progression after ablation treatment,and patient survival after surgical treatment or *** the initial enthusiasm and the accumulating evidence,AI technologies’role i

关键词： Colorectal cancer Liver metastases Artificial intelligence Machine learning Deep learning Neural networks Radiomics

Big size is not all, even better!

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Hepatobiliary Surgery and Nutrition 2019年第5期8卷 539-540页

作者： roberto Ivan Troisi Mariano Cesare Giglio roberto montalti Department of Clinical Medicine and Surgery Federico II University of NaplesNaplesItaly Department of Liver and Small Bowel Transplantation Hepato-Biliary and Pancreatic SurgeryKing Faisal Specialist Hospital and Research CenterRiyadhKingdom of Saudi Arabia Department of Public Health Federico II University of NaplesNaplesItaly

We read with interest the article entitled"Comprehensive Complication Index validates improved outcomes over time despiteincreased complexity in 3707 consecutive hepatectomies"by Cloydet al.(1).This article focused on... 详细信息

关键词： entitled consecutive despite

Liquid biopsy in cholangiocarcinoma:Current status and future perspectives

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World Journal of Gastrointestinal Oncology 2021年第5期13卷 332-350页

作者： Gianluca Rompianesi Marcello Di Martino Alex Gordon-Weeks roberto montalti roberto Troisi Hepato-Bilio-Pancreatic Minimally Invasive and Robotic Surgery UnitDepartment of Clinical Medicine and SurgeryFederico II University HospitalNapoli 80131Italy Hepato-Bilio-Pancreatic Surgery Unit Department of General and Digestive SurgeryHospital Universitario La PrincesaMadrid 28006Spain Nuffield Department of Surgical Sciences University of OxfordOxford OX39DUUnited Kingdom

Cholangiocarcinoma(CCA)are a heterogeneous group of tumors in terms of aetiology,natural history,morphological subtypes,molecular alterations and management,but all sharing complex diagnosis,management,and poor *** mutated genes and epigenetic changes have been detected in CCA,with the potential to identify diagnostic and prognostic biomarkers and therapeutic *** tumoral components and genetic material is therefore crucial for the diagnosis,management and selection of targeted therapies;but sampling tumor tissue,when possible,is often risky and difficult to be repeated at different time *** biopsy(LB)represents a way to overcome these issues and comprises a diverse group of methodologies centering around detection of tumor biomarkers from fluid *** to the traditional tissue sampling methods LB is less invasive and can be serially repeated,allowing a real-time monitoring of the tumor genetic profile or the response to *** this review,we analysis the current evidence on the possible roles of LB(circulating DNA,circulating RNA,exosomes,cytokines)in the diagnosis and management of patients affected by CCA.

关键词： Liquid biopsy Cholangiocarcinoma Circulating biomarkers Biliary tumors Circulating DNA Circulating RNA Exosomes Cytokines

Perioperative thromboprophylaxis in liver transplant patients

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World Journal of Gastroenterology 2018年第27期24卷 2931-2948页

作者： Lesley De Pietri roberto montalti Daniele Nicolini roberto Ivan Troisi Federico Moccheggiani Marco Vivarelli Division of Anaesthesiology and Intensive Care Unit Department of General SurgeryAUSL Reggio Emilia-IRCCSReggio Emilia 42123Italy Hepatobiliary and Abdominal Transplantation Surgery Department of Experimental and Clinical MedicinePolytechnic University of MarcheAncona 60126Italy Department of General Hepatobiliary and Liver Transplantation SurgeryGhent University Hospital Medical SchoolGhent 185 3K3 9000Belgium

Improvements in surgical and anesthetic procedures have increased patient survival after liver transplantation(LT). However, the perioperative period of LT can still be affected by several complications. Among these, thromboembolic complications(intracardiac thrombosis, pulmonary embolism, hepatic artery and portal vein thrombosis) are relatively common causes of increased morbidity and mortality. The benefit of thromboprophylaxis in general surgical patients has already been established, but it is not the standard of care in LT recipients. LT is associated with a high bleeding risk, as it is performed in a setting of already unstable hemostasis. For this reason, the role of routine perioperative prophylactic anticoagulation is usually restricted. However, recent data have shown that the bleeding tendency of cirrhotic patients is not an expression of an acquired bleeding disorder but rather of coexisting factors(portal hypertension, hypervolemia and infections). Furthermore, in cirrhotic patients, the new paradigm of ‘‘rebalanced hemostasis' ' can easily tip towards hypercoagulability because of the recently described enhanced thrombin generation, procoagulant changes in fibrin structure and platelet hyperreactivity. This new coagulation balance, along with improvements in surgical techniques and critical support, has led to a dramatic reduction in transfusion requirements, and the intraoperative thromboembolic-favoring factors(venous stasis, vessels clamping, surgical injury) have increased the awareness of thrombotic complications and led clinicians to reconsider the limited use of anticoagulants or antiplatelets in the postoperative period of LT.

关键词： Anticoagulation Liver transplantation Antiplatelets Thrombosis Coagulation Heparin Thromboelastography Thromboprophylaxis Hepatic artery thrombosis Portal vein thrombosis

Predictive factors of short term outcome after liver transplantation: A review

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World Journal of Gastroenterology 2016年第26期22卷 5936-5949页

作者： Giuliano Bolondi Federico Mocchegiani roberto montalti Daniele Nicolini Marco Vivarelli Lesley De Pietri Anaesthesiology Intensive Care and Pain Therapy Medical Residency University of Modena and Reggio Emilia Division of Hepatobiliary and Transplant Surgery Department of Experimental Medicine Polytechnic University of Marche Division of Anaesthesiology and Intensive Care Unit Department of Cardiology Thoracic and Vascular Surgery Critical Care Medicine Arcispedale Santa Maria Nuova-IRCCS

Liver transplantation represents a fundamental therapeutic solution to end-stage liver disease. The need for liver allografts has extended the set of criteria for organ acceptability, increasing the risk of adverse outcomes. Little is known about the early postoperative parameters that can be used as valid predictive indices for early graft function, retransplantation or surgical reintervention, secondary complications, long intensive care unit stay or death. In this review, we present state-of-the-art knowledge regarding the early post-transplantation tests and scores that can be applied during the first postoperative week to predict liver allograft function and patient outcome, thereby guiding the therapeutic and surgical decisions of the medical staff. Post-transplant clinical and biochemical assessment of patients through laboratory tests (platelet count, transaminase and bilirubin levels, INR, factor V, lactates, and Insulin Growth Factor 1) and scores (model for end-stage liver disease, acute physiology and chronic health evaluation, sequential organ failure assessment and model of early allograft function) have been reported to have good performance, but they only allow late evaluation of patient status and graft function, requiring days to be quantified. The indocyanine green plasma disappearance rate has long been used as a liver function assessment technique and has produced interesting, although not univocal, results when performed between the 1th and the 5th day after transplantation. The liver maximal function capacity test is a promising method of metabolic liver activity assessment, but its use is limited by economic cost and extrahepatic factors. To date, a consensual definition of early allograft dysfunction and the integration and validation of the above-mentioned techniques, through the development of numerically consistent multicentric prospective randomised trials, are necessary. The medical and surgical management of trans

关键词： Liver transplant Liver failure Early allograft dysfunction Primary non-function Initial poor function Outcome predictors Post operative Scoring system Indocyanine green Liver maximal functional capacity

Radiological response and inflammation scores predict tumour recurrence in patients treated with transarterial chemoembolization before liver transplantation

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World Journal of Gastroenterology 2017年第20期23卷 3690-3701页

作者： Daniele Nicolini Andrea Agostini roberto montalti Federico Mocchegiani Cinzia Mincarelli Alessandra Mandolesi Nicola L Robertson roberto Candelari Andrea Giovagnoni Marco Vivarelli Division of Hepatobiliary and Transplant Surgery Department of Experimental and Clinical MedicinePolytechnic University of Marche Division of General and Pediatric Radiology Department of Radiological SciencesPolytechnic University of Marche Division of Interventional Radiology Department of Radiological SciencesPolytechnic University of Marche Division of Pathology Department of PathologyPolytechnic University of Marche Division of Radiology Department of RadiologyMemorial Sloan Kettering Cancer Center

To investigate the prognostic value of the radiological response after transarterial chemoembolization (TACE) and inflammatory markers in patients affected by hepatocellular carcinoma (HCC) awaiting liver transplantation (LT).METHODSWe retrospectively evaluated the preoperative predictors of HCC recurrence in 70 patients treated with conventional (n = 16) or doxorubicin-eluting bead TACE (n = 54) before LT. The patient and tumour characteristics, including the static and dynamic alpha-fetoprotein, neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio (PLR) measurements, were recorded. Treatment response was classified according to the modified Response Evaluation Criteria in Solid Tumours (mRECIST) and the European Association for the Study of the Liver (EASL) criteria as complete response (CR), partial response (PR), stable disease or progressive disease. After examination of the explanted livers, histological necrosis was classified as complete (100% of the cumulative tumour area), partial (50%-99%) or minimal (< 50%) and was correlated with the preoperative radiological *** to the pre-TACE radiological evaluation, 22/70 (31.4%) and 12/70 (17.1%) patients were beyond Milan and University of San Francisco (UCSF) criteria, respectively. After TACE procedures, the objective response (CR + PR) rates were 71.4% and 70.0% according to mRECIST and EASL criteria, respectively. The agreement between the two guidelines in defining the radiological response was rated as very good both for the overall and target lesion response (weighted k-value: 0.98 and 0.93, respectively). Complete and partial histological necrosis were achieved in 14/70 (20.0%) and 28/70 (40.0%) patients, respectively. Using histopathology as the reference standard, mRECIST criteria correctly classified necrosis in 72.9% (51/70) of patients and EASL criteria in 68.6% (48/70) of cases. The mRECIST non-response to TACE [Exp(b) = 9.2, p = 0.012], exceeding UCSF criteria before

关键词： Liver transplantation Recurrence-free survival Hepatocellular carcinoma Radiological response Locoregional therapies Inflammatory markers Selection criteria

Intraoperative thromboelastography as a tool to predict postoperative thrombosis during liver transplantation

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World Journal of Transplantation 2020年第11期10卷 345-355页

作者： Lesley De Pietri roberto montalti Giuliano Bolondi Valentina Serra Fabrizio Di Benedetto Department of General Surgery Division of Anaesthesiology and Intensive Care UnitNuovo Ospedale Civile di SassuoloSassuolo 41049ModenaItaly Department of Public Health Hepato-Pancreato-Biliary Surgery SectionFederico II University of NaplesNapoli 80138Italy Surgery and Trauma Department Intensive Care UnitOspedale Bufalini CesenaCesena 47521Italy Surgery Department Hepato-Pancreato-Biliary SurgerySurgical Oncology and Liver Transplantation UnitAzienda Ospedaliero Universitaria di ModenaUniversity of Modena and Reggio EmiliaModena 41125Italy

BACKGROUND Thromboembolic complications are relatively common causes of increased morbidity and mortality in the perioperative period in liver transplant *** postoperative portal vein thrombosis(PVT,incidence 2%-2.6%)and early hepatic artery thrombosis(HAT,incidence 3%-5%)have a poor prognosis in transplant patients,having impacts on graft and patient *** the present study,we attempted to identify the predictive factors of these complications for early detection and therefore monitor more closely the patients most at risk of thrombotic *** To investigate whether intraoperative thromboelastography(TEG)is useful in detecting the risk of early postoperative HAT and PVT in patients undergoing liver transplantation(LT).METHODS We retrospectively collected thromboelastographic traces,in addition to known risk factors(cold ischemic time,intraoperative requirement for red blood cells and fresh-frozen plasma transfusion,prolonged operating time),in 27 patients,selected among 530 patients(≥18 years old),who underwent their first LT from January 2002 to January 2015 at the Liver University Transplant Center and developed an early PVT or HAT(case group).Analyses of the TEG traces were performed before anesthesia and 120 min after *** retrospectively compared these patients with the same number of nonconsecutive control patients who underwent LT in the same study period without developing these complications(1:1 match)(control group).The chosen matching parameters were:Patient graft and donor characteristics[age,sex,body mass index(BMI)],indication for transplantation,procedure details,United Network for Organ Sharing classification,BMI,warm ischemia time(WIT),cold ischemia time(CIT),the volume of blood products transfused,and conventional laboratory coagulation *** distributed continuous data are reported as the mean±SD and compared using one-way Analysis of Variance(ANOVA).Nonnormally distributed continuous data are rep

关键词： Thromboelastography Hepatic artery thrombosis Portal vein thrombosis Liver transplantation Risk factors Cirrhosis

Transoesophageal echocardiography during liver transplantation

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World Journal of Hepatology 2015年第23期7卷 2432-2448页

作者： Lesley De Pietri Federico Mocchegiani Chiara Leuzzi roberto montalti Marco Vivarelli Vanni Agnoletti Division of Anaesthesiology and Intensive Care Unit Azienda Ospedaliero-Universitaria di Modena-Policlinico Transplantation Unit Polytechnic University of Marche Unit of Interventional Cardiology Arcispedale Santa Maria Nuova IRCCS Division of Anaesthesiology and Intensive Care Unit Arcispedale Santa Maria Nuova IRCCS

Liver transplantation(LT) has become the standard of care for patients with end stage liver disease. The allocation of organs, which prioritizes the sickest patients, has made the management of liver trans-plant candidates more complex both as regards their comorbidities and their higher risk of perioperative complications. Patients undergoing LT frequently display considerable physiological changes during the pro-cedures as a result of both the disease process and the surgery. Transoesophageal echocardiography(TEE), which visualizes dynamic cardiac function and overall contractility, has become essential for perioperative LT management and can optimize the anaesthetic management of these highly complex patients. More-over, TEE can provide useful information on volume status and the adequacy of therapeutic interventions and can diagnose early intraoperative complications, such as the embolization of large vessels or development of pulmonary hypertension. In this review, directed at clinicians who manage TEE during LT, we show why the procedure merits a place in challenging anaesthetic environment and how it can provide essential information in the perioperative management of compromised patients undergoing this very complex surgical procedure.

关键词： Liver transplantation Transoesophageal echocardiog