Rafael S. Pinheiro1, Jin Ye Yeo2
1Digestive Organs Transplant Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil; 2ALES Editorial Office, AME Publishing Company
Correspondence to: Jin Ye Yeo. ALES Editorial Office, AME Publishing Company. Email: ales@amegroups.com
This interview can be cited as: Pinheiro RS, Yeo JY. Readers’ Choice: Author Interview with Dr. Rafael S. Pinheiro. Ann Laparosc Endosc Surg. 2025. Available from: https://ales.amegroups.org/post/view/readers-rsquo-choice-author-interview-with-prof-rafael-s-pinheiro.
Expert introduction
Prof. Rafael S. Pinheiro (Figure 1) is a distinguished surgeon specializing in hepato-bilio-pancreatic surgery and organ transplantation. With a strong foundation in gastroenterology and extensive clinical experience, Prof. Pinheiro has made significant contributions to liver transplantation and intestinal transplantation development in Brazil.
He completed his medical residency in surgery and liver transplantation at the esteemed University of São Paulo, followed by a clinical fellowship at the Catholic University of Leuven under the guidance of Professor Jan Lerut. Since then, he has been at the forefront of liver transplantation, hepatobiliary surgery, and the management of hepatocellular carcinoma at the Hospital das Clínicas, also affiliated with the University of São Paulo.
Prof. Pinheiro's academic achievements are complemented by his robust research portfolio, focusing on various aspects of liver transplantation, hepatobiliary diseases, and surgical outcomes. His research has been published in numerous peer-reviewed journals, contributing to the advancement of knowledge in the field.
Beyond his clinical practice and research, Prof. Pinheiro is an accomplished educator, serving as an assistant professor at the University of São Paulo. He is dedicated to mentoring the next generation of surgeons and fostering innovation in the field of hepato-bilio-pancreatic surgery.
Prof. Pinheiro’s article, “Laparoscopic cholecystectomy and cirrhosis: patient selection and technical considerations”, published in our journal, has received an outstanding readership and entered the journal’s Most Read Article List.
Figure 1 Prof. Rafael S. Pinheiro
Interview
ALES: What motivated you to pursue a career in hepatobiliary medicine, and dedicate your research to focus on liver transplant surgery?
Prof. Pinheiro: My motivation has always been to overcome the challenges posed by this delicate surgery. Beyond the technical complexities of the procedure, there is also the clinical difficulty of managing a chronically ill and debilitated patient. Even simple procedures in cirrhotic patients carry a high risk of complications due to the slightest misstep, and each surgery has the potential to push the boundaries of medical limits.
ALES: Liver transplantation is a highly specialized procedure with a range of challenges. From your experience, what are some of the most critical factors influencing the success of a liver transplant?
Prof. Pinheiro: Liver transplantation relies on a multidisciplinary team working in harmony. This team must consist of highly specialized physicians in various specialties, such as anesthesiologists, surgeons, pathologists, clinical hepatologists, intensivists, and nutrologists, among others. Additionally, we depend on dedicated professionals such as physiotherapists, nurses, pharmacists, psychologists, nutritionists, and many others who together are capable of changing the destiny of patients on the brink of death, giving them a chance at a new beginning.
ALES: Your article titled: “Laparoscopic cholecystectomy (LC) and cirrhosis: patient selection and technical considerations” has gained significant attention (1). What motivated you to write about this topic, and what do you think made this article so well-received by readers?
Prof. Pinheiro: The topic of this article was motivated by the fact that cholecystectomy is a very common procedure and is often performed by general surgeons outside of a specialized liver unit. However, this surgery in the context of cirrhotic patients can present a significant challenge, even in highly specialized centers. Thus, I believe that sharing technical details and the perspective of a reference center for this type of patient can contribute to the dissemination of knowledge of relevant techniques and mitigate potential complications in cirrhotic patients undergoing this type of procedure.
ALES: In the article, you discuss the use of LC becoming the preferred method for treating cholelithiasis in cirrhotic patients What are some unique challenges that cirrhotic patients present during LC, and how do these encounters differ from those encountered in the general population?
Prof. Pinheiro: Patients with cirrhosis generally present with coagulopathy, portal hypertension, increased liver bed stiffness, and chronic inflammation of the gallbladder wall. This combination of factors potentiates inadvertent bleeding due to a minimal wrong movement. Therefore, it is necessary to perform the surgery in a way that avoids any type of inadvertent movement or blunt dissection. Finally, the hepatic remodeling associated with cirrhosis alters the gallbladder from its usual topography, which makes the procedure more difficult when trocars are introduced in the usual manner.
ALES: You also noted that emergency procedures in cirrhotic patients have higher morbidity and mortality compared to elective surgery. What steps can surgeons take to mitigate these risks in an emergency setting?
Prof. Pinheiro: In the context of emergency surgery, redoubled attention is necessary. Surgery should be postponed after clinical stabilization of the patient, and the postoperative period should be carried out within intensive care units. Special care should be taken regarding possible postoperative renal dysfunction, and the use of colloids for volume expansion is often a beneficial strategy in this context.
ALES: From when your article was published in 2017 till now, have there been any new techniques or approaches in managing cirrhotic patients with cholelithiasis that could potentially lower morbidity and mortality rates, especially for high-risk patients?
Prof. Pinheiro: Since the publication of the article, there have been no significant technical modifications. I believe the general idea remains the same, with an emphasis on employing strategies to subject the patient to the surgical procedure in the least severe clinical condition possible, whether through percutaneous puncture or antibiotic treatment and clinical stabilization in the intensive care unit in clinically unstable or Child C patients. Although there is still no broad scientific evidence, the use of active hemostatics could be included in the armamentarium for controlling possible bleeding.
ALES: What do you believe are the most critical areas for future research when it comes to cholecystectomy in cirrhotic patients? Are there any gaps in the current literature that you think need more attention?
Prof. Pinheiro: The future will likely include the introduction of new biomarkers to refine the risk stratification of patients preoperatively. The impact of a customized nutritional follow-up pre and postoperatively is also a potential area of future research.
Reference
- Pinheiro RS, Waisberg DR, Lai Q, et al. Laparoscopic cholecystectomy and cirrhosis: patient selection and technical considerations. Ann Laparosc Endosc Surg 2017;2:35.