This paper is the result of a challenge: putting into reality the H&S principles of teaching and disseminating complex surgery, like hepatobiliary in the case. The analysis of data demonstrates that performing liver resections also in peripheral centers might be safe and effective. Requisites to be successful are: experienced surgeon(s), interdisciplinary meetings to discuss each case and minimum requirements in each hospital such as Intensive Care Unit, interventional radiology and emergency facilities30.
More in detail we want underline that the National Agency for Regional Health Services (AGENAS) has revealed that the Campania Region has lost the 33% of patients affected by HB diseases going to Center-North centres in the country to take care of liver cancers from 2017 to 20229.
To limit health migration, regional health institutions have therefore allowed formal relationships between referral centers and peripheral units to improve patient care in the nearby of their residence, for this reason it is important to test the safeness and effectiveness of the H&S program.
First, it should be considered that baseline characteristics between the two groups of patients are very well balanced after PSM analysis, allowing a reliable analysis of data, considering that patients allocation was not random but consequent to MDT discussions and indications.
Concerning surgical indications, we can affirm that benign pathologies and CRLM resections are performed more common in peripheral centers, on the other hand challenging clinical picture, like HCC, Biliary cancers and biliary injuries are preferably transferred to the referral center. It is clear that the multidisciplinary discussion with both equips decided if it was reliable to treat the patient in the Hub or in the Spoke units, probably also for this reason the most complex procedures were related to Hub.
Before PSM, baseline characteristics of patients who underwent HB surgery at Hub and Spoke Units were aligned with other literature experiences12,31,32. The higher ASA score in Hub Unit (p = 0.0001) and the significative higher number of comorbidities should be noted. Therefore, the use of PSM allowed to homogenize populations to reduce the bias during intra- and post-operative outcomes analysis (Table 1), considering the age and comorbidities impact on postoperative complications23,33.
Intra-operative data revealed superimposable outcomes regarding operative time and type of surgical approaches. After PSM, similar distributions of major and minor liver resection were reported. Despite these findings higher Pringle Maneuver and blood transfusion rates were performed in the Hub Unit, it is probably due to the type of indications and the greater number of cirrhotic patients who needed stricter management of bleeding due to coagulation disorder34. Despite these findings, our data are in line with other literature experiences22,35,36.
Major morbidity and mortality rates range around 15% and 2% respectively, in trend with the standard of care for liver surgery as demonstrated in several reports from high experienced centers37,38,39. Furthermore, the majority of complications are Clavien-Dindo I-II representing more than the 80% of cases40,41.
As main goal of our project we can assess that post-operative complications are similar between centers, except for ICU stay, but it should be clarified that in the HUB center ICU is only a post-operative intensive care where patients stay for 24 h, on the other hand this way of post-operative Intensive Care Unit is not available in spokes where there is only the resuscitation care unit.
From the data analysis, we can infer that several patients affected by benign pathologies or who needed iterative treatments for colorectal cancer or affected by non-complex liver cancers had the chance to be cured in the nearby of their home without any discomfort.
This is one of the benefits of the H&S program which allowed peripheral centers to benefit of the multidisciplinary making process, granting to patients the best therapeutic option, involving all the physicians from oncology to radiology also expanding the learning process in the whole field of cancer therapy.
On the other hand, surgeons from the Hub hospital, who were highly trained, are happy to share their knowledge with the Spokes Unites teams having the opportunity to cure some liver patients in the peripheral centers shortening their waiting lists. At the same time, the training program gave to spoke surgeons the chance to operate more complex patients, improving their skills and treatments offered to their patients.
It is crucial to understand that the H&S learning program is an iterative process that aims to give the chance to peripheral centers to set dedicated HB Units who can manage even more patients achieving autonomy and they can have the help of the training center where patients can be referred in case of need.
One of the weak point of the H&S training program it is always represented by the management of post-operative complications13, but the low distance between centers and the presence in both equips of mentor and training surgeons reduced this criticism, allowing also the mobility of patients from peripheral centers to the Hub in case of need. Furthermore, as depicted in results, there are not statistical evidences of a worse management or higher incidence of complication in the Spoke group.
Patient feelings were also supportive, they were aware of the H&S learning program being more confident about their pathway care without the inconvenience of health mobility. Furthermore the presence of the surgical hospital in the surrounding of their residence improved the early discharge13. This may explain why the LOS in the Hub was longer than in spokes, probably because complex and frail patients are more difficult to discharge when patients are far from the surgical center.
Especially concerning CRLM it is very important to perform liver surgery in the same hospital where patients underwent primary resection and chemotherapy, taking advantage of continuity of care.
Noticeably, the objective of our learning program is not to convert peripheral centers into referral centers for HPB, Hub centers remain the referral for complex cases and specific indications.
Our goal is to reduce costs of health mobility and improve the surgical knowledge physicians always offering the best care management of liver pathologies.
The age of images has undoubtedly shortened the learning curve, particularly in HPB surgery. To look and look via videos at the surgical field closer as never before, has raised more quickly surgeons able to face open difficult surgery and particularly HPB one42,43,44,45.
Conversely, Viganò et al.30 reported, through a CUSUM analysis, that a learning curve of 60 cases is necessary for laparoscopic hepatectomies. Others have reported that the learning curve for Minimally Invasive Hepatectomies (MIH) ranges widely, from 20 to over 80 cases30,46,47.
In case of open hepato-biliary surgery the learning curve significantly decreases but it is always related to the type of hepatectomy, major or minor ones48,49.
Limitations
Our analysis showed some limitations, first of all it is a retrospective analysis, furthermore Spoke Units shows different characteristics in terms of surgical and hospital facilities. Despite of PSM analysis based on pre- and intra-operative data of patients, unknown confounders might have a significant impact on post-operative outcomes.
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