Explore the vast range of titles available.

BackgroundSurgical resection remains the best therapeutic option for the long-term survival of patients with perihilar cholangiocarcinoma (PCC).1 For patients presenting with Bismuth type 3 or 4 tumors, left or right extended liver resection has been shown to be feasible.2 The Achilles heel of the procedure remains biliary reconstruction due to multiple small-diameter remnant liver bile ducts.3 This study showed how a Kasai-like portoenterostomy allows circumvention of this difficulty.MethodsA 57-year-old woman with a type 3a PCC invading the main portal vein bifurcation underwent a right hepatectomy with en bloc resection of segment 4b, the caudate lobe, and the extrahepatic common bile duct; hepatic pedicle lymphadenectomy; and main portal vein bifurcation reconstruction.4 The cross-section of the left biliary plate was tumor-free at frozen section analysis but involved three small biliary ducts originating from segments 2, 3, and 4a. The biliary plate and the distance between each duct were too large to allow unification. A Roux-en-Y portoenterostomy, inspired by the Kasai procedure,5 was performed between the umbilical plate and the extramucosal wall of an efferent Roux-en-Y jejunal limb. Two temporary external trans-portoenterostomy drains were placed according to the Voelker technique.ResultsThe postoperative course was uneventful, and the patient was discharged on postoperative day 8. The two trans-portoenterostomy drains were removed after 6 weeks, and patient was disease-free at the 2-year follow-up evaluation.ConclusionsIn extended PCC, Kasai-like portoenterostomy may facilitate complex biliodigestive reconstructions when multiple biliary ducts are involved.

BackgroundVascular leiomyosarcomas (LMS) are rare malignant mesenchymal tumors arising from vessel smooth muscle cells. They represent only 2% of soft tissue sarcomas and most commonly (50%) originate from the inferior vena cava.1–3 Portal vein LMS are very rare, and their resection combines en bloc negative margin sarcoma surgery principles and complex liver surgery procedures with vascular reconstructions.3–5MethodsThis is the case of a 42-year-old female presenting with a moderate cholestasis. Imaging revealed a 3-cm tumor originating from the main portal vein and its right branch while being in contact with both the right hepatic artery and biliary confluence. No metastases were identified. Core needle biopsy confirmed the diagnosis and tumor board decision was surgical resection.ResultsThe procedure included anatomic right hepatectomy with en bloc resection of the portal vein bifurcation, common bile duct, and biliary confluence. Portal venous reconstruction was performed using an autogenous external iliac vein interposition graft, while biliary reconstruction was performed via a Roux-en-Y end-to-side hepatico-jejunostomy. Duration of surgery was 300 min, and blood loss was 300 ml. Postoperative outcomes were uneventful and patient was discharged on postoperative day 8 with a transient right limb edema. Pathology confirmed R0 resection of a T1N0M0 leiomyosarcoma, Fédération Nationale des Centres de Lutte Contre le Cancer (FNCLCC) grade 2 tumor. Patient was free of disease at 20 months post-surgery.ConclusionsPortal vein leiomyosarcomas are extremely rare. En bloc extensive surgical resection should be proposed to obtain R0 resection, and achieve prolonged survival.4,6,7

Background: Pancreatic cancer, a frequently fatal disease with severe symptoms, can require high-intensity end-of-life (HI-EOL) care, posing challenges to patients’ well-being. The examination of HI-EOL care to develop tailored interventions in the management of pancreatic cancer is a critical, yet underexplored area. Objectives: The objective of this study was to assess the factors that influence the intensity of end-of-life (EOL) care in France. Design: A retrospective study of patients registered in the French Nationwide database who were hospitalized in France for pancreatic adenocarcinoma from January 1, 2014 to December 31, 2019, and subsequently died during the follow-up period. Methods: Data on patient demographics, clinical characteristics, hospitalization details, and palliative care were collected. The primary outcome measure was the evaluation of HI-EOL care, defined by indicators such as death in an intensive care unit (ICU), multiple hospitalizations, and chemotherapy administration within the last 30 days of life. Secondary outcomes included indicators of most-intensive EOL (MI-EOL) care and invasive procedures (IP). Univariate and multivariate logistic regression analyses were conducted to identify factors associated with each outcome measure. Results: A total of 42,696 patients who died from pancreatic adenocarcinoma were included. Among them, 41.1% experienced HI-EOL, with the most common indicators being multiple hospitalizations and death in an ICU, emergency room, or acute care unit. A smaller proportion (2.8%) received MI-EOL care, while 28.1% underwent IPs in the last 30 days of life. The multivariate analysis revealed that male gender and follow-up in non-cancer specialized care facilities were associated with a higher risk of HI-EOL. Conversely, palliative care involvement and older age at death were identified as protective factors. Male gender, older age at death, and palliative care involvement were associated with lower rates of MI-EOL care and IPs. Conclusion: These results underscore the importance of palliative care integration and individualized approaches in improving the EOL quality of care and patient outcomes for individuals with advanced pancreatic cancer.

Pancreatic neuroendocrine tumors (p-NETs) are rare tumors with a recent growing incidence. In the 2017 WHO classification, p-NETs are classified into well-differentiated (i.e., p-NETs grade 1 to 3) and poorly differentiated neuroendocrine carcinomas (i.e., p-NECs). P-NETs G1 and G2 are often non-functioning tumors, of which the prognosis depends on the metastatic status. In the localized setting, p-NETs should be surgically managed, as no benefit for adjuvant chemotherapy has been demonstrated. Parenchymal sparing resection, including both duodenum and pancreas, are safe procedures in selected patients with reduced endocrine and exocrine long-term dysfunction. When the p-NET is benign or borderline malignant, this surgical option is associated with low rates of severe postoperative morbidity and in-hospital mortality. This narrative review offers comments, tips, and tricks from reviewing the available literature on these different options in order to clarify their indications. We also sum up the overall current data on p-NETs G1 and G2 management.

Other than location of the primary colorectal cancer (CRC), a few factors are known to influence the intrahepatic distribution of colorectal cancer liver metastases (CRLM). We aimed to assess whether the anatomy of the portal vein (PV) could influence the intrahepatic distribution of CRLM. Patients with CRLM diagnosed between January 2018 and December 2022 at two tertiary centers were included and imaging was reviewed by two radiologists independently. Intra-operator concordance was assessed according to the intraclass correlation coefficient (ICC). The influence of the diameter, angulation of the PV branches and their variations on the number and distribution of CRLM were compared using Mann-Whitney, Kruskal-Wallis, Pearson's Chi-square and Spearman's correlation tests. Two hundred patients were included. ICC was high (> 0.90, P < 0.001). Intrahepatic CRLM distribution was right-liver, left-liver unilateral and bilateral in 66 (33%), 24 (12%) and 110 patients (55%), respectively. Median number of CRLM was 3 (1-7). Type 1, 2 and 3 portal vein variations were observed in 156 (78%), 19 (9.5%) and 25 (12%) patients, respectively. CRLM unilateral or bilateral distribution was not influenced by PV anatomical variations (P = 0.13), diameter of the right (P = 0.90) or left (P = 0.50) PV branches, angulation of the right (P = 0.20) or left (P = 0.80) PV branches and was independent from primary tumor localisation (P = 0.60). No correlations were found between CRLM number and diameter (R: 0.093, P = 0.10) or angulation of the PV branches (R: 0.012, P = 0.83). PV anatomy does not seem to influence the distribution and number of CRLM.

Adult large bowel intussusception represents a small minority of intestinal intussusceptions. Main causes involve primary or secondary bowel malignancies. Although multiple small intestine intussusceptions have already been reported, simultaneous large bowel intussusceptions have not been described in the literature so far. Adult large bowel intussusception represents a small minority of intestinal intussusceptions. Main causes involve primary or secondary bowel malignancies. Although multiple small intestine intussusceptions have already been reported, simultaneous large bowel intussusceptions have not been described in the literature so far.

Background: Pancreatic fistula (PF), i. e., a failure of the pancreatic anastomosis or closure of the remnant pancreas after distal pancreatectomy, is one of the most feared complications after pancreatic surgery. PF is also one of the most common complications after pancreatic surgery, occurring in about 30% of patients. Prevention of a PF is still a major challenge for surgeons, and various technical and pharmacological interventions have been investigated, with conflicting results. Pancreatic exocrine secretion has been proposed as one of the mechanisms by which PF occurs. Pharmacological prevention using somatostatin or its analogs to inhibit pancreatic exocrine secretion has shown promising results. We can hypothesize that continuous intravenous infusion of somatostatin-14, the natural peptide hormone, associated with 10–50 times stronger affinity with all somatostatin receptor compared with somatostatin analogs, will be associated with an improved PF prevention. Methods: A French comparative randomized open multicentric study comparing somatostatin vs. octreotide in adult patients undergoing pancreaticoduodenectomy (PD) or distal pancreatectomy with or without splenectomy. Patients with neoadjuvant radiation therapy and/or neoadjuvant chemotherapy within 4 weeks before surgery are excluded from the study. The main objective of this study is to compare 90-day grade B or C postoperative PF as defined by the last ISGPF (International Study Group on Pancreatic Fistula) classification between patients who receive perioperative somatostatin and octreotide. In addition, we analyze overall length of stay, readmission rate, cost-effectiveness, and postoperative quality of life after pancreatic surgery in patients undergoing PD. Conclusion: The PreFiPS study aims to evaluate somatostatin vs. octreotide for the prevention of postoperative PF.

Background Laparoscopic right anterior sectionectomy (LRAS) remains a technically demanding procedure as it requires two transection planes where the middle and right hepatic veins run; however, the main difficulty is locating these two planes 1 – 3 . The aim of this video was to show the technique of an LRAS performed with a transparenchymal glissonean pedicle approach and guided by indocyanine green (ICG) staining. Methods This was the case of an 80-year-old man with a history of hemochromatosis and normal liver function. He was diagnosed with a 6 cm hepatocellular carcinoma (HCC) located at segment 8, close to the right anterior pedicle. Results The technique consisted of parenchymal transection along the main portal fissure along the right border of the middle hepatic vein. Opening the liver facilitated access to the right anterior glissonean pedicle and selective transparenchymal clamping. A negative-stain ICG test permitted to demarcate the transection line along the right lateral portal fissure. The parenchymal transection was carried out in a caudal approach, along two perfectly marked planes, preserving the middle and right hepatic veins. The duration of the procedure was 200 min and blood loss was 300 mL. Postoperative course was uneventful and the patient was discharged on the third postoperative day. Conclusion Guidance during resection, and protection of the right posterior pedicle and right hepatic vein are the key points of the LRAS. The glissonean approach and the ICG imaging technology are of great help in resolving these difficulties.