Virtual hepatectomy and metastasectomy 3D simulation using an automated and semiautomated tool applied to preoperative CT in the treatment of colorectal cancer metastases.

Colorectal cancer represents the most common malignancy of the gastrointestinal tract and the second most frequently diagnosed malignancy in adults. The most common site of metastases is the liver and 40% of patients in stage IV have liver only disease.1 Hepatic metastases are the major determinants of morbidity and mortality in these patients, with surgery being the treatment of choice or even curative in these cases.2 Therefore, aggressive surgeries should be considered in patients with liver only disease. In this context, hepatectomy and metastasectomy have emerged as promising techniques for improving survival in patients with metastatic disease, also providing long-term cure.3 The use of liver volumetrics, tridimensional reconstructions with vessel extraction and 3D virtual surgery simulations allows better surgical planning and potentially decrease transfusions, surgery time and complications.4 For major hepatectomies (>4 resected segments), surgical planning with computed angiotomography and liver remnant volume calculation potentially increases the safety of surgery. We report a case in which preoperative 3D surgical simulation was crucial for conducting a safe major hepatectomy in a patient with multiple colorectal liver metastases.

Endoscopic Treatment of Complex Walled-Off Necrosis in Necrotizing Pancreatitis With Two Simultaneous Lumen-Apposing Metal Stents: A Case Report.

Organized pancreatic and peripancreatic collections are complications of pancreatitis and should be treated when symptomatic or complicated. When feasible, the endoscopic ultrasound approach presents high efficacy and low morbidity and mortality, making it the first likely option. Among the available accessories for endoscopic drainage, the lumen-apposing metal stent can be a better option, with a low migration rate; furthermore, it allows endoscopic necrosectomy. Here, we present the case of complex walled-off necrosis treated with two lumen-apposing metal stents in the same procedure. A 41-year-old male patient with walled-off necrosis presented with delayed gastric emptying and obstruction of the main biliary duct. Magnetic resonance imaging and endoscopic ultrasound revealed two non-communicating collections. We opted for endoscopic ultrasound-guided drainage with the deployment of two simultaneous lumen-apposing metal stents: one transduodenal and the other transgastric, with clinical improvement. After three weeks, endoscopic retrograde cholangiopancreatography showed a biliary fistula communicating with the periduodenal collection, which was treated with a biliary plastic stent. An endoscopic necrosectomy was performed, and the metal stents were removed. Control magnetic resonance imaging demonstrated improvement. The patient was asymptomatic at the six-month follow-up. The treatment of symptomatic complex walled-off necrosis remains a challenge and may require multiple endoscopic approaches; moreover, surgical treatment may be necessary in case of failure. In the present report, we demonstrate that the deployment of two lumen-apposing metal stents in the same procedure is feasible when necessary as it was associated with technical success and short-term clinical success.