Tailoring the Use of Central Pancreatectomy Through Prediction Models for Major Morbidity and Postoperative Diabetes: International Retrospective Multicenter Study.

OBJECTIVE: To develop a prediction model for major morbidity and endocrine dysfunction after CP which could help in tailoring the use of this procedure. SUMMARY BACKGROUND DATA: Central pancreatectomy (CP) is a parenchyma-sparing alternative to distal pancreatectomy for symptomatic benign and pre-malignant tumors in body and neck of the pancreas CP lowers the risk of new-onset diabetes and exocrine pancreatic insufficiency compared to distal pancreatectomy but it is thought to increase the risk of short-term complications including postoperative pancreatic fistula (POPF). METHODS: International multicenter retrospective cohort study including patients from 51 centers in 19 countries (2010-2021). Primary endpoint was major morbidity. Secondary endpoints included POPF grade B/C, endocrine dysfunction, and the use of pancreatic enzymes. Two risk model were designed for major morbidity and endocrine dysfunction utilizing multivariable logistic regression and internal and external validation. RESULTS: 838 patients after CP were included (301 (36%) minimally invasive) and major morbidity occurred in 248 (30%) patients, POPF B/C in 365 (44%), and 30-day mortality in 4 (1%). Endocrine dysfunction in 91 patients (11%) and use of pancreatic enzymes in 108 (12%). The risk model for major morbidity included male sex, age, BMI, and ASA score≥3. The model performed acceptable with an area under curve (AUC) of 0.72(CI:0.68-0.76). The risk model for endocrine dysfunction included higher BMI and male sex and performed well (AUC:0.83 (CI:0.77-0.89)). CONCLUSIONS: The proposed risk models help in tailoring the use of CP in patients with symptomatic benign and premalignant lesions in the body and neck of the pancreas and are readily available via www.pancreascalculator.com.

Technical Aspects of a Posterior Pancreatic Head Enucleation - An Organ-Sparing Alternative to Pancreatico-Duodenectomy for Benign and Low-Grade Malignant Pancreatic Tumors.

From a technical point of view, enucleation can be challenging for a few locations with hard access, such as the posterior pancreatic head, particularly for deeply-located lesions, in close relationship with the main pancreatic duct (MPD). The risk of MPD injuries with secondary pancreatic fistula is high in these specific situations. Hereby we describe a technique of posterior pancreatic head enucleation in a 48-year-old male patient diagnosed with a deeply-located branch duct type intraductal papillary mucinous neoplasm (BD-IPMN). A posterior pancreatic head enucleation of the BD-IPMN was performed along with segmental resection of the MPD and end-to-end anastomosis, with protection by a plastic stent passing both through the MPD anastomosis and major duodenal papilla. No protective pancreatico-jejunostomy was necessary. A grade B pancreatic fistula complicated the postoperative course, and a grade A delayed gastric emptying, both conservatively managed. Enucleation of deeply-located tumors at the dorsal pancreatic head is challenging but feasible and safe. Segmental resection of the MPD with end-to-end anastomosis protected by a transpapillary plastic stent for injuries during enucleation can be safely performed. Thus, the operative time during enucleation is reduced, and the potential morbidity of a pancreaticojejunostomy is eliminated.

Pancreatico-Duodenectomy for Pancreatic Ductal Adenocarcinoma: from Artery-First Approaches toTRIANGLE Operation.

Pancreatico-duodenectomy (PD) is the single hope for long-term survival in a patient with pancreatic head ductal adenocarcinoma (PDAC). Unfortunately, even after curative intent PD, the long-term survival of patients with PDAC remains under expectations, with high recurrence rates, including the loco-regional ones. Positive resection margins after resection of PDAC are frequent, and they have a detrimental effect on both recurrence and long-term survival rates, particularly the R1 (direct) ones, toward the mesopancreas. In the last years, there were made increased efforts by surgeons to introduce in clinical practice several technical refinements to the standard technique of PD better to resect the tumor, including an accurate lymph node dissection, hoping to increase the rate of negative resection margins, to decrease local recurrence rates and to improve prognosis. Furthermore, to extend the number of patients with resectable disease, a few surgical techniques were also intended to convert to resectability the patients with the regional disease (i.e., anatomical borderline resectable and locally advanced PDAC) in the context of multimodal therapies, particularly neoadjuvant therapies. With this, we briefly discuss a few technical refinements addressing the resection time of PD, like the artery-first approaches and the Triangle operation. Both surgical techniques aim for better clearance of the retroperitoneal space for nerves, lymphatic nodes, and vessels, including total mesopancreas excision.

The Optimal Management of Distal Pancreatic Stump After Pancreatico-Duodenectomy: Different Indications for Gastric and Jejunal Anastomoses.

BACKGROUND/AIM: The optimal management of distal pancreatic stump after pancreaticoduodenectomies (PD) remains unclear. The study aims to assess the early outcomes after anastomoses with jejunum vs. stomach of the distal pancreatic stump in a relatively large series of patients with PD. Patients and Methods: All patients with PD performed between Oct 1, 2016, and Oct 1, 2021, were retrospectively assessed: anastomoses with the jejunum (PJ group) vs. with the stomach (PG group). Results: A number of 360 PD: PJ group 293 patients (81.4%) and PG group 67 patients (18.6%). No statistically significant differences were observed between the groups regarding the early outcomes (p values 0.065), except for the clinically relevant delayed gastric emptying higher rates in the PG group (38.8% vs. 25.9%, p = 0.049). In the PG group there were statistically significant higher rates of pylorus-preservation (19.4% vs. 8.2%, p = 0.012), soft pancreas texture (76.1% vs. 34.4%, p 0.001), small Wirsung ducts (4 mm (0-25) vs. 3 mm (1-10), p 0.001) and intermediate and high-risk fistula scores (83.6% vs. 52.6%, p 0.001). Conclusions: No particular anastomotic technique can avoid postoperative complications. In patients with hard pancreas texture and dilated Wirsung duct, a duct-to-mucosa PJ anastomosis should be the first option, while for patients with small Wirsung duct and soft pancreas texture, an invagination PG anastomosis should be preferred.

Using Molecular Subtyping of Pancreatic Ductal Adenocarcinoma for Multimodal Treatment Selection in Resectable Disease.

Pancreatic ductal adenocarcinoma (PDAC) is characterized by high heterogeneity; thus, even after a curative intent surgery, there is significant variability in the survival of patients, reflecting different biological behaviors. The selection of proper, personalized therapy for each patient with resectable PDAC, in multimodal therapy, by an experienced multidisciplinary team is of utmost importance to get maximal clinical benefit avoiding potentially harmful treatments. Identifications of patients with resectable PDAC that would benefit from surgical resections in the context of multimodal therapy remain a topic of interest for clinical practice. To improve PDAC patient outcomes, a significant step forward would be the integration of the molecular sub-types in the clinical decision-making between upfront surgery versus neoadjuvant treatment. Successful integration of the preoperative knowledge of the subtype of PDAC can properly guide this treatment selection to further improve patient outcomes. In this review, we present an overview of the current knowledge on the role of molecular subtyping in surgical decisions for PDAC patients.

Central pancreatectomy: a comprehensive, up-to-date meta-analysis.

BACKGROUND: Central pancreatectomy (CP) is the alternative to distal pancreatectomy (DP) for specific pathologies of the mid-pancreas. However, the benefits of CP over DP remain controversial. This study aims to compare the two procedures by conducting a meta-analysis of all published papers. METHODS: A systematic search of original studies comparing CP vs. DP was performed using PubMed, Scopus, and Cochrane Library databases up to June 2018. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) checklist was followed. RESULTS: Twenty-one studies were included (596 patients with CP and 1070 patients with DP). Compared to DP, CP was associated with significantly higher rates of overall and severe morbidity (p < 0.0001), overall and clinically relevant pancreatic fistula (p < 0.0001), postoperative hemorrhage (p = 0.02), but with significantly lower incidences of new-onset (p < 0.0001) and worsening diabetes mellitus (p = 0.004). Furthermore, significantly longer length of hospital stay (p < 0.0001) was observed for CP patients. CONCLUSIONS: CP is superior to DP regarding the preservation of pancreatic functions, but at the expense of significantly higher complication rates and longer hospital stay. Proper selection of patients is of utmost importance to maximize the benefits and mitigate the risks of CP.

Caudate Lobectomy for Perihilar Cholangiocarcinoma - Current Evidence.

At the moment, surgery is considered the only therapeutic approach offering a chance of long-term survival in patients diagnosed with perihilar cholangiocarcinoma (PHC). Curative intent surgery for PHC has experienced significant technical improvements over the years, from simple bile duct resection to complex surgical procedures including lymph nodes dissection, major hepatectomies and, sometimes, vascular resections. The modern surgical approach of PHC is associated with significantly improved survival rates, albeit with increased postoperative morbidity. The initial Western experience with major hepatectomies for PHC was not encouraging, as it was associated with unacceptably high mortality rates. Currently the mortality rates after surgery for PHC have significantly decreased, but it appears that the mortality rates in Western centres still remain higher, compared with the East Asian centres. The differences of outcomes between East Asian and Western centres are explained not only by the management of PHC but also by patient characteristics. En bloc caudate lobectomy as part of radical resections for PHC has been reported in clinical practice nearly three decades ago. The rationale of en bloc caudate lobectomy is based on the pattern of tumour spread in PHC, taking in consideration the fact that caudate lobe invasion appears to be a frequent event in patients resected for PHC. While en bloc caudate lobectomy in the context of curative intent surgery for PHC has been discussed in a host of publications so far, the currently available literature reached conflicting results regarding its overall impact on the patient. Therefore, the aim of this paper is to review the current relevant literature pertaining to the impact of en bloc caudate lobectomy in the context of curative intent surgery for PHC.

Retrohepatic Gallbladder Masquerading as Hydatid Cyst in a Patient with Right Liver Agenesis.

Agenesis of the right liver is a rare congenital anomaly which can be associated with an ectopic gallbladder. Hereby, it is presented the case of a 39-year-old man investigated for right upper quadrant abdominal pain and diagnosed at computed tomography with a cystic liver mass initially considered as hydatid cyst. At laparotomy, it was discovered agenesis of the right liver and the presumed hydatid cyst was a retrohepatic gallbladder with lithiasis. Cholecystectomy was performed with an uneventful outcome. Reassessment of the computed tomography images by an experienced radiologist confirmed the intraoperative diagnosis. Although agenesis of the right liver with retrohepatic gallbladder is an exceptional appearance, surgeons should be aware of this anomaly because it can raise challenging issues of diagnosis and surgical planning during cholecystectomy.

Technical Issues and Early Outcomes of Restorative Proctocolectomy for Familial Adenomatous Polyposis and Ulcerative Colitis: The Largest Romanian Single-Team Experience.

Background/ Aim: Restorative proctocolectomy (RPC) is a complex surgical procedure used to treat patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). The present study aims to assess the technical issues and early outcomes of RPC for FAP and UC, in a relatively large single-team series of patients. Patients and Methods: The data of all patients with RPC performed by a single surgical team between 1991 and 2018 were retrospectively assessed from a prospectively maintained electronic database. Results: The study group included 77 patients with RPC, and 70.1% have had FAP. The average number of RPC per year was 3.3 for the surgical team and 4.3 for the institution. A J pouch was performed in 93.5% of the patients. A hand-sewn reservoir was made in 76.6% of the patients. A hand-sewn ileal pouch-anal anastomosis was performed in 81.8% of the patients. A diverting ileostomy was performed in 92.2% of the patients. Mucosectomy was performed in 84.4% of the patients. The early morbidity rate was 36.4%, with severe complications rate of 13%. The main complications were pouch-related septic complications (18.2%), wound infections (9.1%), small-bowel obstruction (6.5%) and hemorrhage (6.5%). Conclusions: Although a RPC remains an uncommon surgical procedure in Romania, however, the early outcomes of the present series are comparable to those reported in high volume centers. Good outcomes after RPC can be obtained if such complex surgical procedures are performed by dedicated surgical teams, with high case-load.

Outcomes After Distal Pancreatectomy with Celiac Axis Resection for Pancreatic Cancer: A Pan-European Retrospective Cohort Study.

BACKGROUND: Western multicenter studies on distal pancreatectomy with celiac axis resection (DP-CAR), also known as the Appleby procedure, for locally advanced pancreatic cancer are lacking. We aimed to study overall survival, morbidity, mortality and the impact of preoperative hepatic artery embolization (PHAE). METHODS: Retrospective cohort study within the European-African Hepato-Pancreato-Biliary-Association, on DP-CAR between 1-1-2000 and 6-1-2016. Primary endpoint was overall survival. Secondary endpoints were radicality (R0-resection), 90-day mortality, major morbidity, and pancreatic fistulae (grade B/C). RESULTS: We included 68 patients from 20 hospitals in 12 countries. Postoperatively, 53% of patients had R0-resection, 25% major morbidity, 21% an ISGPS grade B/C pancreatic fistula, and 16% mortality. In total, 82% received (neo-)adjuvant chemotherapy and median overall survival in 62 patients with pancreatic ductal adenocarcinoma patients was 18 months (CI 10-37). We observed no impact of PHAE on ischemic complications. CONCLUSIONS: DP-CAR combined with chemotherapy for locally advanced pancreatic cancer is associated with acceptable overall survival. The 90-day mortality is too high and should be reduced. Future studies should investigate to what extent increasing surgical volume or better patient selection can improve outcomes.

Correction to: Outcomes After Distal Pancreatectomy with Celiac Axis Resection for Pancreatic Cancer: A Pan-European Retrospective Cohort Study.

In the original article, the institutional author the E-AHPBA DP-CAR study group was misspelled. It is correct as reflected here. The original article has also been corrected.

Is Hepatitis B Virus a Player in Pancreatic Cancer?

Pancreatic cancer (i.e., pancreatic ductal adenocarcinoma, PDAC) is an important healthcare issue and a highly lethal disease. Thus, almost 80% of patients with PDAC will die within one year after diagnosis. Several factors including smoking, obesity, advanced age, diabetes mellitus and chronic pancreatitis have been associated with increased risk of PDAC. Hepatitis B virus (HBV) infection is also considered as a risk factor for PDAC development in some studies. However, the role of HBV infection in PDAC is poorly explored. The present paper reviews the current relevant literature exploring the impact of HBV infection in PDAC. Assessment of HBV infection impact in PDAC is challenging because its effects could be easily underestimated. Indeed, the role played by occult B infection (OBI) and intrinsic difficulties to detect HBV antigens or DNA in pancreatic tissue remains major limitations to further progress. To date a significant proportion of available literature suggests the potential oncogenic role of HBV in PDAC but experimental evidences remain scarce. Remarkably, it appears that HBV infection might influence some clinical and pathological features of patients with PDAC. Future researches to better define the role of HBV infection in developing PDAC are urgently needed.

What is the Value of Total Mesopancreas Excision in Pancreatic Ductal Adenocarcinoma? Current Evidence of the Literature.

Pancreatic ductal adenocarcinoma (PDAC) is a disease with a grim prognosis. Pancreatectomy represents the single hope for long-term survival in a patient with PDAC. Recurrence is a common event after curative-intent surgery for PDAC, mainly related to incomplete removal at the site of resection margins; medial/ superior mesenteric margins are the most often positive. The concept of total mesopancreas excision (TMpE) in PDAC was proposed in analogy to the concept of total mesorectal excision for rectal cancer, to better control loco-regional recurrence. This paper aims to discuss the current evidence for the value of TMpE in PDAC.

D2 Lymphadenectomy for Gastric Adenocarcinoma: Long-term Results and the Impact of Surgeon Experience on the Survival Rates.

Background: Surgery is the main component of the multimodality treatment of gastric cancer (GC). The present study aims to comparatively assess the early and long-term outcomes after D1 and D2 lymph node dissection. Furthermore, the impact of surgeon case-load on the long-term survival after D2 gastrectomies is also explored. Methods: A number of 773 patients with curative-intent surgery for GC adenocarcinoma (1997 - 2010: 325 patients with D1 lymphadenectomy, 448 patients with D2 lymphadenectomy) were included. Results: No statistically significant differences of overall morbidity rates were observed between the D1 and D2 groups of patients (16.3%for D1 group vs. 18.8% for D2 group, p = 0.39). However, statistically significant higher rates of post operative pancreatic fistulae rates were observed in the D2 group of patients (3.2% for D1 group vs. 7.9% for D2 group, p 0.001). Interestingly, statistically significant higher rates of mortality were observed for the D1 group of patients (8.9% for D1 group vs. 2.9% for D2 group, p 0.001). The 5-year survival rate was statistically significant higher in the D2 group of patients (median overall survival time of 18 months for D1 group vs. 60 months for D2 group, p 0.001). A statistically significant correlation (p=0.005, r=0.571) was observed between the overall survival time and the number of D2 lymphadenectomies performed by each surgeon. Conclusions: D2 lymph node dissection is associated with statistically significant improved longterm survivals at the expense of higher postoperative pancreatic fistulae rates, compared to D1 surgery. However, no increased mortality rates were observed in the D2 group of patients. D2 radical gastrectomies should be performed in high-volume centers by high case-load surgeons.

One Hundred Pancreatectomies with Venous Resection for Pancreatic Adenocarcinoma.

Introduction: Invasion of portal vein (PV)/ superior mesenteric vein (SMV) in pancreatic ductal adenocarcinoma (PDAC) is no longer a contraindication for resection when reconstruction is technically feasible. However, the literature data reached conflicting conclusions regarding the early and long-term outcomes of patients with venous resection and pancreatectomies for PDAC. The study aims to present the outcomes in a large series of patients with pancreatectomies and associated PV/ SMV resection for PDAC, in a single center experience. Patients Methods: The data of 100 patients with pancreatectomies and PV and/ or SMV resection performed between 2002 and 2016 (February, 1st) were retrospectively analyzed from a prospectively maintained electronic database, which included 474 pancreatectomies for PDAC. Only patients with a final pathological diagnosis of PDAC were included in the present study. Results: Overall, 21.1% of patients with pancreatectomies for PDAC required a venous resection (100 patients out of 474 patients). Segmental resection was performed in 77 patients (out of 100 patients with pancreatectomies and venous resection - 77%), while 23 patients (23%) have had tangential venous resection. In the group of patients with segmental venous resection, reconstruction was made by end-to-end anastomosis in 53 patients (out of 77 patients - 68.8%), while in 24 patients (out of 77 patients - 31.2%) a graft interposition was necessary. Negative resections margins were obtained in 63 patients (63%). Histological tumor invasion of the resected vein was confirmed in 64 patients (64%). Postoperative complications occurred in 47 patients (47%), with severe complications (i.e., Dindo-Clavien grade III-V) in 19 patients (19%). Postoperative pancreatic fistulae, delayed gastric emptying and post-pancreatectomy hemorrhage rates were 9%, 20% and 15%, respectively. PV/ SMV thrombosis occurred in 5 patients (5%). The 90-day mortality rate in the group of patients with venous only resection, without any associated procedures, was 8%. Adjuvant treatment was performed in 63 patients (63%), while only 2 patients (2%) underwent neoadjuvant chemotherapy. Median follow-up time was 105 months (range, 3 - 186 months), with a median overall survival time of 13 months (range, 3 - 186 months). In the group of patients with negative resection margins, the median overall survival time was 16 months (range, 3 - 186 months). Conclusions: PV/ SMV resection during pancreatectomies for PDAC is technically feasible, and grafts are rarely required for venous reconstruction. However, venous resection is associated with high postoperative complications rates, and the mortality rate is not neglectable. The main goal of such complex procedure is to obtain negative resection margins, a situation associated with encouraging survival rates.

Gastric Cancer, Hemophilia A and Angiodysplasia - An Unreported Association with Clinical Implications in a Patient with Digestive Hemorrhage.

Introduction: Gastric cancer is a rare cause of upper digestive hemorrhage. Associated co-morbidities may have a detrimental effect on both early and long-term outcomes after surgery for gastric cancer. Association of gastric adenocarcinoma with hemophilia A and angiodysplasia was not previously reported, and the impact on postoperative outcome is not known. Case Report: A 49-year-old male with inherited hemophilia A presented with upper digestive hemorrhage and severe anemia, and was diagnosed with gastric carcinoma. The patient underwent total gastrectomy with splenectomy and D2 lymph nodes dissection. The postoperative outcome was complicated by digestive hemorrhage due to the presence of lesions of angiodysplasia of the cecum and jejunum that were successfully treated with coils mounted by the interventional radiologic approach. During the pre and postoperative periods, the patient received human coagulation factor VIII and developed auto-antibodies against factor VIII. Thus, human coagulation factor VIII administration was stopped and replaced with factor eight inhibitor bypassing activity (FEIBA). The patient was discharged at home on postoperative day 41, without any signs of bleeding. Conclusion: To the best of our knowledge, this is the first reported association of gastric adenocarcinoma, hemophilia A and angiodysplasia. All these lesions may lead to digestive hemorrhage and can pose very difficult problems of decision for diagnosis and therapy. A multidisciplinary approach including hematologist, surgeon, anesthesiologist, endoscopist and the interventional radiologist is mandatory to have a proper diagnosis and management for these patients.

An Attempt to Build a National Prospective Electronic Database for Pancreaticoduodenectomies in Romania - Preliminary Results of the First Year Enrollment.

Introduction: National databases for pancreaticoduodenectomies (PD) have contributed to better postoperative outcomes after such complex surgical procedure because the multicentre collection of data allowed more reliable analyses with quality assessment and further improvement of technical issues and perioperative management. The current practice and outcomes after PD are poorly known in Romania because there was no national database for these patients. Thus, in 2016 a national-intent electronic registry for PD was proposed for all Romanian surgical centers. The study aims to present the preliminary results of this national-intent registry for PD after one-year enrollment. Patients Methods: The database was started on October 1st, 2016. Data were prospectively collected with an electronic online form including 102 items for each patient. The registry was opened to all the Departments of Surgery from Romania performing PD, with no restriction. Results: During the first year of enrollment were collected the data of 181 patients with PD performed by 24 surgeons from four surgical centers. The age of patients was 64 years (28 - 81 years), with slightly male predominance (61.3%). Computed tomography was the main preoperative imaging investigation (84.5%). All the PDs were performed by an open approach. The Whipple technique was used in 53% of patients, and a venous resection was required in 14.3% of cases. A posterior approach PD was considered in 16.6% of patients. The stomach was used to treat the distal remnant pancreas in 50.1% of patients. The operative time was 285 min (110 - 615 min), and the estimated blood loss was 400 ml (80 - 3000 ml). The overall morbidity rate was 55.8%, with severe (i.e., grade III-IV Dindo-Clavien) morbidity rate of 10%, and 3.9% in-hospital mortality rate. The overall pancreatic fistula, delayed gastric emptying and hemorrhage rates were 19.9%, 39.8% and 15.5%. Periampullary malignancies were the main indications for PD (78.9%), with pancreatic cancer on the top (48%). Conclusions: To build a prospective electronic online database for PD in Romania appears to be a feasible project and a useful tool to know the current practice and outcomes after PD in our country. However, improvements are still required to encourage a larger number of surgical centers to introduce the data of patients with PD.

Simultaneous Breast and Liver Surgery in a Patient with Stage IV Triple Positive Breast Cancer - A Case Report.

Introduction: In the modern context of multimodal treatment strategies for cancer patients with systemic disease, the dogma that surgery has a limited role is becoming less and less valid. Although a "œcurative" approach is not possible for the majority of the cases, however, some patients with limited systemic disease and favorable tumor biology could benefit from an aggressive combined cytotoxic and surgical strategy. CASE REPORT: A 48-year-old patient was diagnosed with an invasive ductal carcinoma with the immunohistochemistry positive for estrogen and progesterone receptors, positive Her2 and three liver metastases. After nine cycles of chemotherapy, a favorable tumor response was identified at the level of the primary tumor as well as for the liver lesions: two of the metastases have disappeared, and the third one decreased in dimensions. The patient was operated in our unit, a lumpectomy together with a level II axillary lymph nodes dissection and a non-anatomic resection of the segment V of the liver was performed. Conclusions: A subgroup of patients with stage IV breast cancer with limited liver metastases and no extrahepatic disease might benefit from an aggressive combined cytotoxic and surgical strategy regarding disease control and overall survival.

Curative-intent Surgery for Perihilar Cholangiocarcinoma with and without Portal Vein Resection - A Comparative Analysis of Early and Late Outcomes.

Introduction: The safety of portal vein resection (PVR) during surgery for perihilar cholangiocarcinoma (PHC) has been demonstrated in Asia, America, and Western Europe. However, no data about this topic are reported from Eastern Europe. The aim of the present study is to comparatively assess the early and long-term outcomes after resection for PHC with and without PVR. PATIENTS AND METHODS: The data of 21 patients with PVR were compared with those of 102 patients with a curative-intent surgery for PHC without PVR. The appropriate statistical tests were used to compare different variables between the groups. Results: A PVR was performed in 17% of the patients. In the PVR group, significantly more right trisectionectomies (p=0.031) and caudate lobectomies (0.049) were performed and, as expected, both the operative time (p=0.015) and blood loss (p=0.002) were significantly higher. No differences between the groups were observed regarding the severe postoperative morbidity and mortality rates, and completion of adjuvant therapy. However, in the PVR group the postoperative clinicallyrelevant liver failure rate was significantly higher (p=0.001). No differences between the groups were observed for the median overall survival times (34 vs. 26 months, p = 0.566). A histological proof of the venous tumor invasion was observed in 52% of the patients with a PVR and was associated with significantly worse survival (p=0.027). CONCLUSION: A PVR can be safely performed during resection for PHC, without significant added severe morbidity or mortality rates. However, clinically-relevant liver failure rates are significantly higher when a PVR is performed. Furthermore, increased operative times and blood loss should be expected when a PVR is performed. Histological tumor invasion of the portal vein is associated with significantly worse survival.

Bouveret Syndrome - An Exceptional Complication of a Very Frequent Disease.

The Bouveret syndrome is an exceptional complication of the gallbladder lithiasis. Hereby it is described the case of a patient with a history of gallstones complicated on the long-term outcome with gastric outlet obstruction, due to a large gallstone of the duodenum, migrated via a cholecysto-duodenal fistula. The clinical, radiological features and the patient management are described.