Hepatobiliary

Luca Aldrighetti

Years of experience: 20

Doctor of Philosophy (PhD) Research Degree in Technological Applications and Experimental Methods in Surgery.
Specialization in General Surgery.
Specialization in Chest Surgery.

As chief surgeon (2004-2015), he has performed over 1900 major hepatopancreatobiliary surgery procedures, consisting mainly of resections of the liver and pancreas [typical and extensive hepatectomy and lobectomy, central hepatectomy, hepatic sectoriectomy and segmentectomy, resection of the biliary carrefour, hepatic cystopericystectomy, duodenocephalopancreasectomy and splenopancreatic resection].
He is skilled in the laparoscopic approach to major hepatobiliary surgery, having, in particular, launched and developed himself the laparoscopic hepatic resection programme of San Raffaele Hospital, including major and minor resections conducted both using the classical laparoscopic technique and the LESS (LaparoEndoscopic Single Site) technique with the largest number of cases handled in Italy according to the National Survey of Minimally-Invasive Liver Surgery (2012). More than 300 laparoscopic resections have been performed up to now.
He is chairman of the Italian Group of Minimally Invasive Liver Surgery (IGoMILS) and coordinates the Italian prospective register of minimally invasive liver resections.
He is director of the Italian School of Minimally Invasive Liver Surgery, set up under the auspices of the Italian Group of Minimally Invasive Liver Surgery (IGoMILS).
He was a member of the ”expert panel” at the 2nd International Consensus Conference on Laparoscopic Liver Surgery (Morioka, Japan; 2014) and the 1st International ALPPS Consensus Conference (Hamburg, Germany; 2015).

CLINICAL ACTIVITY
The healthcare and clinical research activities are dedicated exclusively to the diagnosis and treatment of hepatobiliary cancer, the treatment of portal hypertension and terminal liver failure, and the monitoring and treatment of critical surgery patients.
The Hepatobiliary Surgery Unit has:

  • 13 beds specifically for hepatobiliary surgery patients, located in a modern department with all the necessary instruments for post-operative monitoring
  • 1 operating theatre with the very latest surgical and anaesthesia instruments for hepatobiliary surgery operations, with specific technologies for minimally invasive liver surgery.

OUTPATIENT DEPARTMENTS FOR LIVER AND BILE DUCT DISEASES
The Hepatobiliary Surgery Unit is dedicated to the integrated treatment of benign and malignant diseases of surgical interest, with top priority and specific attention to primitive tumours (hepatocarcinoma, cholangiocarcinoma, rare tumours) and secondary tumours (hepatic metastasis from colorectal cancer, neuroendocrine cancer and non-colorectal, non-neuroendrocrine cancer) of the liver and bile ducts (Klatskin tumour, extrahepatic cholangiocarcinoma).
Particular attention is paid constantly to the multidisciplinary approach to patients with liver cancer, the diagnostic-therapeutic process being tailored to each individual patient by a multidisciplinary team – including a liver surgeon, cancer specialist, medical hepatologist, interventional radiologist and radiotherapist – during a specific weekly meeting (MMEB – Multidisciplinary Hepatobiliary meeting). This multidisciplinary and dedicated approach appears critically important above all in some “niche” sectors, such as Klatskin tumour, in which a specific, dedicated and multidisciplinary commitment has enabled the Hepatobiliary Surgery Unit of San Raffaele Hospital to optimize its cancer treatment results and significantly reduce the risks of surgery. The volume and intensity of the surgical activity is centred on the patient’s needs, so that waiting times are limited and suited to the severity of the diagnosis and the consequent need for a rapid, efficient and effective treatment.
The recent, major evolution of the liver surgery techniques and technologies and the considerable complexity of the issues involved in liver cancer, do not allow the latest, most suitable and integrated treatment of liver cancer patients to be administered in a non-specifically dedicated general surgery environment. It is for this reason that the staff and facilities of the Hepatobiliary Surgery Unit of San Raffaele Hospital have been dedicated exclusively  - for over ten years – to the acquisition of extensive skills in all fields of liver surgery, performing over 2000 liver resections (currently about 200 resections/year) including all kinds of conventional liver resections (major hepatectomy, minor hepatectomy, ultrasound-guided parenchymal sparing resections), specific extensive resection programmes (two-stage hepatectomy, ALPPS) and laparoscopic, minimally-invasive resections.

MINIMALLY-INVASIVE LIVER SURGERY PROGRAMME
The Minimally-Invasive Liver Surgery Programme (Laparoscopic Liver Surgery) has been in operation for about 10 years and the Hepatobiliary Surgery Unit is the recognized leader on a national and international level.
The laparoscopic approach to liver resection surgery has only recently been introduced in clinical practice and, despite its exponential growth, has not yet spread or been standardized in other fields of general surgery due to its peculiar characteristics (technical difficulties in the mobilization and transection of the liver, intraoperative haemorrhagic complications). Nevertheless, a recent meta-analysis (Mirnezami, HPB, 2013) has confirmed the advantages of laparoscopic surgery over open surgery in terms of intraoperative blood loss, post-operative hospital stays, overall morbidity. Initial studies also suggest that economic advantages (Abu Hilal, Surg Endoscopy, 2013) can be obtained from the systematic use of minimally-invasive techniques. Further studies and experiences are however necessary to define the actual role of laparoscopic techniques in liver surgery and to investigate further some issues that remain open.
In this setting, the Hepatobiliary Surgery Unit of San Raffaele Hospital plays a leading role on a national and international level. The elements that characterize this leadership comprise:

  • The design of an original liver transection technique (Aldrighetti et al., The American Journal of Surgery 2008; 195: 270–272), and the first application of an even more minimally-invasive technique (single-port technique) to liver resections (Aldrighetti et al., Surg Endoscopy 2012; 26: 2016-2022)
  • The significant contribution to the construction of the international scientific literature through:
  • Conduction of the first comparative prospective clinical trials that demonstrated the advantages of the laparoscopic approach in terms of post-operative pain and the length of post-operative hospital stays (Aldrighetti et al., J Gastrointest Surg 2008; 12: 457-462);
  • Conduction of the first systematic review (Aldrighetti, Nature Clin Pract Gastroenterol Hepatol. 2008; 5:648-654) that documented the advantages of the laparoscopic approach
  • Contribution of the San Raffaele Hospital dataset for the conduction of the first world systematic review (Nguyen, Ann Surg, 2008)
  • Production of scientific papers (period 2008-2010) subsequently selected and used for the international meta-analyses that showed the general advantages of laparoscopic surgery (Mirnezami, HPB, 2013) and the specific advantages in surgery of the hepatocarcinoma (Zhou, Dig Dis Sci, 2013)
  • Constant production of original scientific papers with a retrospective or prospective design, which are published regularly in international magazines with IF
  • The clinical cases handled currently amount to 352 laparoscopic liver surgery operations and represent the largest series in Italy and one of the largest in the Western world
  • Dr. Aldrighetti, Director of the Hepatobiliary Surgery Unit of San Raffaele Hospital, was responsible for coordinating and analysing the data of the first Italian Survey of Minimally-Invasive Liver Surgery (2012), which covered 1497 liver resections performed at 39 Italian centres (Aldrighetti et al. Italian experience in minimally invasive liver surgery: a national survey. Updates Surg, 2015)
  • Dr. Aldrighetti is also a member of the Board of the Italian Group Of Minimally-Invasive Liver Surgery (I GO MILS) and chairman of the Italian Association of the same name, I GO MILS, and responsible for coordinating the Italian prospective laparoscopic liver resection register, enrolling over 400 patients in its first year of activity
  • Dr. Aldrighetti was a member of the expert panel at the 2nd International Consensus Conference on Laparoscopic Liver Surgery, held in Morioka, Japan in 2014 (Wakabayashi G et al. Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka. Ann Surg 2015)
  • The Hepatobiliary Surgery Unit of the San Raffaele Hospital is also taking part in international, multi-centre, randomized, prospective studies to determine the clinical and economic advantages of laparoscopic surgery over open surgery conducted on the basis of fast-track protocols (ERAS) in minor resections (ORANGE II – Trial) and major resections (ORANGE II Plus Trial), and is, at the moment, one of the centres that has enrolled the largest number of patients (ORANGE II Plus)
  • Dr. Aldrighetti is the coordinator of the Italian School of Minimally-Invasive Liver Surgery (San Raffaele Hospital – Coordinating Centre). The School holds a teaching course for the professional training of surgeons, which provides the theoretical and practical notions necessary for the students to tackle the problems of minimally-invasive liver surgery with adequate technical and decision-making competence and autonomy. The three-week course consists of two weeks of teaching activities (the first and third weeks) at the Organizing Centre, where the entire class of students receives theoretical and practical teaching, and one week (second week) at one of the reference centres, where each student takes part individually in the surgical activity under the guidance of one of the School’s tutors.

PERIHILAR TUMOUR SURGERY PROGRAMME
Perihilar cholangiocarcinoma is the most frequent form (about 65%) of cholangiocarcinoma, that is, a primitive liver tumour that originates in the epithelial cells of the bile ducts (cholangiocytes). At present, the only potentially curative treatment is surgical resection of the biliary carrefour and removal of the hemiliver affected by the disease. About 30-35% of the patients suffering from this kind of disease are eligible for surgical treatment at the time of the diagnosis, while the remaining 65-70% are not (due to the presence of a locally advanced disease or metastasis).
The diagnosis and treatment of perihilar cholangiocarcinoma require a multidisciplinary approach with synergistic collaboration of surgeons, gastroenterologists, radiologists, cancer specialists and radiotherapists, and the preoperative management and preparation of the patient have not yet spread or been standardized in other fields of general surgery due to its peculiar characteristics (need for major liver resections and inadequate residual liver volume, need to manage preoperative jaundice). At the Hepatobiliary Surgery Unit of San Raffaele Hospital, the specialists collaborate to standardize and optimize the treatment of this disease, while maintaining the “patient-tailored therapy” philosophy.
The Hepatobiliary Unit of San Raffaele Hospital also plays an important role on a national and international level. The elements that characterize this leadership comprise:

  • The design of an original preoperative optimization protocol (Aldrighetti et al., World J Surg. 2013 Jun;37(6):1388-96), and the study of predictive factors for long-term outcomes with a view to personalizing treatment further (Aldrighetti et al., J Gastrointest Surg. 2015 Jul;19(7):1324-33.)

SCIENTIFIC ACTIVITY
The main fields of the current scientific activity are: liver resection surgery and complementary/adjuvant treatments for primitive and metastatic tumours of the liver, with particular reference to hepatocarcinoma and metastasis from colorectal carcinoma; surgery and complementary treatments for tumours of the bile ducts (intrahepatic cholangiocarcinoma, gallbladder tumour, Klatskin tumour); laparoscopic liver resections; LESS surgery in liver resection surgery; technical and biological aspects of liver resection surgery; pathophysiology of the hepatic ischemia-reperfusion syndrome; ERAS (Enhanced Recovery After Surgery in liver resection surgery) programme.
The following international, multi-centre collaboration projects are also in progress: (1) Study of the long-term outcomes and prognostic factors of hepatobiliary cancer surgery coordinated by the Hepatobiliary Surgery Program Center for Surgical Trials and Outcomes Research (Director Timothy M. Pawlik) - John Hopkins Hospital, (Baltimore, MD, USA). (2) Study of the impact of the ERAS (Enhanced Recovery After Surgery) programme in laparoscopic liver resection surgery, coordinated by the Department of Surgery (promoters R. Van Dam, EM. Wong-Luin-Hing), Maastricht University Medical Centre (Maastricht, The Netherlands) (3) Study of the short and long-term outcomes and the prognostic factors of laparoscopic hepatobiliary surgery, in collaboration with the Department of Surgery (Dr. Mohammad Abu Hilal) - University Hospital Southampton NHS Foundation Trust (Southampton, UK), Department of Surgery (Prof. Roberto Troisi) – Ghent University Hospital Medical School (Ghent, Belgium); Department of Hepatobiliary Surgery - Oslo universitetssykehus (Oslo, Norway) (4) ALPPS international registry, international register for assessing the short and long-term outcomes of the ALPPS procedure.
A member of 12 scientific societies; a member of the Board of Directors of the Italian Chapter of the International HepatoPancreatoBiliary Association (IHPBA) in the period 2008-2010.
Peer Reviewer for Italian and international surgical oncology magazines, Member of the Editorial Board of Updates in Surgery, the official magazine of the Italian Society for Surgery.
Member of the Reviewer Association of the MIUR (Ministry of Education, University and Research) for the assessment of the products of research conducted in the field of RQA in the period 2004-2010.

SCIENTIFIC PRODUCTION (UP TO 23/11/2015)
The author and co-author of 522 scientific publications, which include 210 articles, published in extenso in Italian and international magazines and proceedings, and 312 abstracts of speeches at conferences.

IMPACT FACTOR
137 articles were published in magazines with Impact Factor. The Cumulative Impact Factor (JCR 2012) is 363,959 with a mean Impact Factor of 3.60.

TEACHING ACTIVITY

  • Teaching at the Specialization Schools in General Surgery and Surgery of the Digestive System –Vita-Salute San Raffaele University
  • Theoretical and practical training courses in Liver Resection Surgery (San Raffaele Hospital) held once every three months
  • Medical Expert Training in Liver Surgery (San Raffaele Hospital) courses held once every three months
  • Italian Academy of Medicine – Advanced course in Open and Laparoscopic Liver Surgery. Laparoscopic techniques, San Raffaele Hospital (clinical part) and the Spallanzani CRABCC centre (experimental part)
  • Training course in “Multidisciplinary approach to synchronous liver metastases from colorectal carcinoma. The tough challenge”. San Raffaele Hospital
  • Teacher on the European Fellowship program on Laparoscopic Liver Surgery (San Raffaele Hospital – Reference Centre)
  • Coordinator and Teacher at the Italian School of Minimally-Invasive Liver Surgery (San Raffaele Hospital –Coordinating Centre).