Extended Left Hepatectomy Research Articles

Liver Resection Under Total Hepatic Vascular Exclusion with In Situ Hypothermic Isolated Hepatic Perfusion for Advanced Liver Tumors.

Continuous dissection or simultaneous reconstruction of the hepatic vein (HV) and inferior vena cava (IVC) was achieved under total hepatic vascular exclusion (THVE) with in situ hypothermic isolated hepatic perfusion (HIHP) in two cases. CASE 1: The patient previously underwent liver resections with the right HV for colorectal liver metastasis (CRLM). This time, the CRLM had invaded the left HV and IVC, and five courses of FOLFILI plus ramucirumab were given, resulting in stable disease. Due to expected high HV pressure, liver parenchymal transection was started under THVE. Sub-segmentectomy with patch graft plasty of the IVC and reconstruction of the left HV using a jugular vein graft were performed under THVE and HIHP. This patient died at home 3 months after surgery; the cause of death was unknown. CASE 2: Hepatocellular carcinoma in the caudate lobe was in extensive contact with the roots of three main HVs and the IVC, and pressed the hepatocaval confluence, with high HV pressure expected. In addition, tumor thrombosis extended to both the main portal vein and the common bile duct, resulting in the inability to introduce chemotherapy. After tumor thrombectomy, liver parenchymal transection was started under THVE. Extended left hepatectomy with wedge resection, and primary suture of the right HV and IVC was performed under THVE and HIHP. Recurrence-free and overall survivals were 8 months (lung metastasis) and 31 months, respectively. In liver resection for liver tumors located in the hepatocaval confluence, THVE with HIHP is useful for ensuring the safety.

Higher Postoperative Mortality and Inferior Survival After Right-Sided Liver Resection for Perihilar Cholangiocarcinoma: Left-Sided Resection is Preferred When Possible.

A right- or left-sided liver resection can be considered in about half of patients with perihilar cholangiocarcinoma (pCCA), depending on tumor location and vascular involvement. This study compared postoperative mortality and long-term survival of right- versus left-sided liver resections for pCCA. Patients who underwent major liver resection for pCCA at 25 Western centers were stratified according to the type of hepatectomy-left, extended left, right, and extended right. The primary outcomes were 90-day mortality and overall survival (OS). Between 2000 and 2022, 1701 patients underwent major liver resection for pCCA. The 90-day mortality was 9% after left-sided and 18% after right-sided liver resection (p<0.001). The 90-day mortality rates were 8% (44/540) after left, 11% (29/276) after extended left, 17% (51/309) after right, and 19% (108/576) after extended right hepatectomy (p<0.001). Median OS was 30 months (95% confidence interval [CI] 27-34) after left and 23 months (95% CI 20-25) after right liver resection (p<0.001), and 33 months (95% CI 28-38), 27 months (95% CI 23-32), 25 months (95% CI 21-30), and 21 months (95% CI 18-24) after left, extended left, right, and extended right hepatectomy, respectively (p<0.001). A left-sided resection was an independent favorable prognostic factor for both 90-day mortality and OS compared with right-sided resection, with similar results after excluding 90-day fatalities. A left or extended left hepatectomy is associated with a lower 90-day mortality and superior OS compared with an (extended) right hepatectomy for pCCA. When both a left and right liver resection are feasible, a left-sided liver resection is preferred.

Short-term outcomes of laparoscopic extended hepatectomy versus major hepatectomy: a single-center experience

IntroductionLaparoscopic major hepatectomy (LMH) remains restricted to a few specialized centers and poses a challenge to surgeons performing laparoscopic resections. Laparoscopic extended resections are even more complex and rarely conducted. MethodsFrom a single-institution database, we compared the short-term outcomes of patients who underwent major and extended laparoscopic resections, stratifying the entire retrospective cohort into four groups: right hepatectomy, left hepatectomy, right extended hepatectomy, and left extended hepatectomy. Patient demographics, tumor characteristics, operative variables, and especially postoperative outcomes were evaluated. Results250 patients underwent major and extended laparoscopic liver resections, including 160 right, 31 right extended, 36 left, and 23 left extended laparoscopic hepatectomies. The most common indication for resection was colorectal liver metastases (64%). Laparoscopic extended hepatectomy (LEH) showed significantly longer operative time, more blood loss, need for Pringle maneuver, conversion to open surgery, higher rates of liver failure, postoperative ascites, and intra-abdominal hemorrhage, R1 margins and length of stay when compared with the LMH group. Mortality rates were similar between groups. Multivariate analysis revealed intraoperative blood transfusion (OR = 5.1[CI-95%: 1.15–6.79]; p = 0.02) as an independent predictor for major complications. ConclusionsLEH showed to be feasible, however with higher blood loss and significantly associated to major complications.

Early Outcomes of Extended Hepatectomy: An Experience from the University Hospital of Nepal.

Background Extended hepatectomy (≥ 5 liver segments resection) may be required to have a complete surgical resection and provide the best chance of cure of hepatobiliary tumors. It is associated with high morbidity and mortality but with good perioperative care, its outcomes can be improved. This study was conducted to evaluate the early outcomes of extended hepatectomy at a university hospital in Nepal. Methods For this study, prospectively collected data from all patients who underwent extended hepatectomy from October 2012 to April 2022 were reviewed and analyzed retrospectively. Demographic data, liver volume augmentation methods used, intraoperative variables, and postoperative complications were analyzed. Results Seventeen patients underwent extended hepatectomy from October 2012 to April 2022. Among them 11 (64.7%) were female and the mean age was 53.9 ±16.3 years (18-72 years). Right extended hepatectomy was the most commonly performed procedure (n = 15, 88.2%), and left extended hepatectomy was performed inthe remaining (n = 2, 11.8%). Six patients underwent liver volume augmentation procedures (35.3%) with portal vein embolization (PVE) in three, portal vein ligation (PVL) in one, and partial associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in two patients. Overall complications were 70% with major complications (Clavien Dindo ≥ IIIa) constituting 35.3%. The most common hepatectomy-specific complication was post-hepatectomy liver failure(PHLF) in six cases. The 30-day mortality was 17.6% (three patients). Conclusion Extended hepatectomy can be performed with acceptable major complications and mortality rates in selected patients.

Extended left hepatectomy with inferior vena cava reconstruction and veno-venous bypass for alveolar echinococcosis (with video).

Extended left hepatectomy with inferior vena cava reconstruction and veno-venous bypass for alveolar echinococcosis (with video).

Surgical Outcomes of Hepatectomy with Vascular Resection for Colorectal Liver Metastases

Introduction: Liver resection combined with vascular reconstruction is a curative option for hepatic metastases with vascular invasion. However, vascular surgery during major liver resection significantly increases morbidity and mortality. This study aims to assess the results of vascular resection and reconstruction during hepatectomy for colorectal liver metastases (CLM). Methods: We conducted a descriptive study to evaluate surgical outcomes of CLM patients who underwent hepatectomy with vascular resection. A prospectively collected database was reviewed from January 2019 to May 2021. Results: Overall, 10 hepatectomies in 9 CLM patients were included in the study (3 female and 6 male). The median age was 57 (IQR: 53-61) years. Performed procedures included 4 right hepatectomies, 2 right extended hepatectomies, 2 left extended hepatectomies, 1 central hepatectomy, and 1 segmentectomy of 4B liver segment. Vascular surgery involved 3 portal vein resections, 6 hepatic vein resections, and 1 simultaneous portal vein and hepatic artery resection. Median total liver ischemia time was 50 (IQR: 21-84) min. Median operative time was 375 (IQR: 225-585) min. Median blood loss was 900 (IQR: 250-2000) mL and 4 patients (40%) required blood transfusions. R0 rate was 90%. The 90-day major morbidity (Clavien-Dindo grade III-V) and mortality were 80% and 33%. Median ICU and hospital stays were 3 (IQR: 1-5) and 18 (IQR: 9-33) days. Conclusion: Hepatectomy with vascular resection is feasible for CLM with vascular invasion and demonstrates outcomes comparable with available data from high-volume centers.Tabled 1EP01C-017No.SexAge (years)Type of hepatectomyType of VRLiver ischemia time (min)Operating time (min)Blood loss (mL)Morbidity (CD grade)Death cause1M55RHLPV756701,500IIIbNA2M59CHLHV110350800IIIaNA3F61LEHRHV21290600Vsmall-for-size syndrome4M53REHRHV844003,500IIIaNA5F49RHMHV30200250IIIbNA6F72RHPVC15225250INA7F72SMHV20180100INA8M52REHLHA, PV605854,000Vmassive bleeding9M57LEHLHV, MHV1076602,000Vliver failure10M57RHPV404101,000IIIbNABMI, body mass index; CD, Clavien-Dindo; CH central hepatectomy; F, female; LEH, left extended hepatectomy; LHA, left hepatic artery; LHV, left hepatic vein; LPV, left portal vein; M, male; MHV, middle hepatic vein; NA, not applicable; OR, operating room; PV, portal vein; PVC, portal vein confluence; REH, right extended hepatectomy; RH, right hepatectomy; RHV, right hepatic vein; S, segmentectomy; VR, vascular resection and reconstruction Open table in a new tab BMI, body mass index; CD, Clavien-Dindo; CH central hepatectomy; F, female; LEH, left extended hepatectomy; LHA, left hepatic artery; LHV, left hepatic vein; LPV, left portal vein; M, male; MHV, middle hepatic vein; NA, not applicable; OR, operating room; PV, portal vein; PVC, portal vein confluence; REH, right extended hepatectomy; RH, right hepatectomy; RHV, right hepatic vein; S, segmentectomy; VR, vascular resection and reconstruction

Magnetic compression anastomosis for bile duct stricture after extended left hepatectomy

Magnetic compression anastomosis for bile duct stricture after extended left hepatectomy

Probiotic-related bacteremia after major hepatectomy for biliary cancer: a report of two cases

BackgroundProbiotics have been reported to be beneficial for the prevention of postoperative complications and are often used during the perioperative period. Among the probiotic-related adverse events, bacteremia is rare. Here, we report two cases of probiotic-related bacteremia after major hepatectomy for biliary cancer.Case presentation 1A 74-year-old man was referred to our hospital to be treated for gallbladder cancer. Neoadjuvant chemotherapy, two courses of gemcitabine plus S-1 combination therapy, was administered. Extended right hepatectomy with caudate lobectomy, extrahepatic bile duct resection and biliary reconstruction were performed 3 weeks after chemotherapy. Probiotics, Clostridium butyricum (C. butyricum) MIYAIRI 588, were administered 6 days before surgery and continued after surgery. Sepsis of unknown origin occurred 17 days after surgery and developed into septic shock. C. butyricum was detected in blood cultures at postoperative day 26 and 45. After stopping the probiotic agent, C. butyricum was undetectable in the blood cultures. The patient died due to an uncontrollable sepsis 66 days after surgery.Case presentation 2A 63-year-old man with diabetes mellitus whose past history included total colectomy, papillectomy, and Frey’s operation at the age of 19, 34 and 48, respectively, was referred to our hospital to be treated for perihilar cholangiocarcinoma. Extended left hepatectomy with caudate lobectomy, extrahepatic bile duct resection and reconstruction of bile duct were performed. Probiotics were administered during the perioperative period. Combined probiotics that included lactomin, amylolytic bacillus and C. butyricum, were given before surgery. C. butyricum MIYAIRI 588 was given after surgery. Sepsis occurred 16 days after surgery and developed to respiratory failure 8 days later. Blood culture at postoperative day 25 revealed Enterococcus faecalis and C. butyricum. After the probiotics were stopped at postoperative day 27, C. butyricum was not detected in the blood culture. The general condition improved with intensive care. The patient was transferred to another hospital for rehabilitation at postoperative day 156.ConclusionIt should be noted that the administration of probiotics in severe postoperative complications can lead to probiotic-related bacteremia.

A tailored approach in lymph node-positive perihilar cholangiocarcinoma

PurposeExtended right hepatectomy is associated with wide surgical margins in PHC and often favored for oncological considerations. However, it remains uncertain whether established surgical principles also apply to the subgroup of node-positive patients. The aim of the present study was to define a tailored surgical approach for patients with perihilar cholangiocarcinoma (PHC) and lymph node metastases.MethodsWe reviewed the course of all consecutive patients undergoing major hepatectomy for PHC between 2005 and 2015 at the Department of Surgery, Charité – Universitätsmedizin Berlin.ResultsTwo hundred and thirty-one patients underwent major hepatectomy for PHC with 1-, 3-, and 5-year overall (OS) and disease-free survival (DFS) rates of 72%, 48%, and 36%, and 60%, 22%, and 12%, respectively. In lymph node-positive patients (n = 109, 47%), extended left hepatectomy was associated with improved OS and DFS, respectively, when compared to extended right hepatectomy (p = 0.008 and p = 0.003). Interestingly, OS and DFS did not differ between R0 and R1 resections in those patients (both p = ns). Patients undergoing extended left hepatectomy were more likely to receive adjuvant chemotherapy (p = 0.022). This is of note as adjuvant chemotherapy, besides grading (p = 0.041), was the only independent prognostic factor in node-positive patients (p=0.002).ConclusionPatients with node-positive PHC might benefit from less aggressive approaches being associated with lower morbidity and a higher chance for adjuvant chemotherapy. Lymph node sampling might help to guide patients to the appropriate surgical approach according to their lymph node status.

The use of neoadjuvant lobar radioembolization prior to major hepatic resection for malignancy results in a low rate of post hepatectomy liver failure.

Neoadjuvant yttrium-90 transarterial radioembolization (TARE) is increasingly being used as a strategy to facilitate resection of otherwise unresectable tumors due to its ability to generate both tumor response and remnant liver hypertrophy. Perioperative outcomes after the use of neoadjuvant lobar TARE remain underinvestigated. A single center retrospective review of patients who underwent lobar TARE prior to major hepatectomy for primary or metastatic liver cancer between 2007 and 2018 was conducted. Baseline demographics, radioembolization parameters, pre- and post-radioembolization volumetrics, intra-operative surgical data, adverse events, and post-operative outcomes were analyzed. Twenty-six patients underwent major hepatectomy after neoadjuvant lobar TARE. The mean age was 58.3 years (17-88 years). 62% of patients (n=16) had primary liver malignancies while the remainder had metastatic disease. Liver resection included right hepatectomy or trisegmentectomy, left or extended left hepatectomy, and sectorectomy/segmentectomy in 77% (n=20), 8% (n=2), and 15% (n=4) of patients, respectively. The mean length of stay was 8.3 days (range, 3-33 days) and there were no grade IV morbidities or 90-day mortalities. The incidence of post hepatectomy liver failure (PHLF) was 3.8% (n=1). The median time to progression after resection was 4.5 months (range, 3.3-10 months). Twenty-three percent (n=6) of patients had no recurrence. The median survival was 28.9 months (range, 16.9-46.8 months) from major hepatectomy and 37.6 months (range, 25.2-53.1 months) from TARE. Major hepatectomy after neoadjuvant lobar radioembolization is safe with a low incidence of PHLF.

Locally advanced cholangiolocellular carcinoma successfully treated with curative resection after downsizing chemotherapy: a case report

BackgroundCholangiolocellular carcinoma (CoCC) is an extremely rare disease comprising less than 1% of all primary malignant liver tumors. No effective treatment other than resection has been established. Herein, we report a case of locally advanced CoCC diagnosed as unresectable, which was successfully treated with curative resection after downsizing chemotherapy.Case presentationA 59-year-old Japanese woman with chronic hepatitis B was diagnosed with locally advanced intrahepatic cholangiocellular carcinoma. As it was difficult to perform R0 resection in the local hospital, chemotherapy combined with gemcitabine plus cisplatin was administered every 3 weeks. After a total of 10 courses of chemotherapy over 10 months the tumor was shown to be reduced in size by computed tomography imaging, and she was referred to our department for surgical resection. The effect of chemotherapy was classified as a “partial response” in the response evaluation criteria of solid tumors. After adding one course of chemotherapy, an extended left hepatectomy with resection of the caudate lobe was performed. R0 resection was achieved. Based on the pathological findings, the final diagnosis of CoCC was determined and eight courses of S-1 adjuvant chemotherapy were administered. At 14 months after the operation, the patient was alive without tumor recurrence.ConclusionsDownsizing chemotherapy with gemcitabine and cisplatin may be an effective treatment strategy in locally advanced CoCC. Further evidence is required to establish an optimal strategy for the treatment of locally advanced CoCC.

Postsegmentectomy for a Local Recurrence of Hilar Cholangiocarcinoma after Central Bisegmentectomy and Caudal Lobectomy

Introduction: Surgical resection is the only curative treatment for hilar cholangiocarcinoma but the possibility of local recurrence is high. The standard treatment for recurrent hilar cholangiocarcinoma after operation is chemotherapy and repeated resection is rarely performed. We herein report a rare case that re-hepatectomy was done for a local recurrence of hilar cholangiocarcinoma after central bisegmentectomy and caudal lobectomy. Methods: A report of a case. Results: A 75-year-old woman developed hilar cholangiocarcinoma and underwent extrahepatic bile duct resection with concomitant central bisegmentectomy and caudal lobectomy. The histopathological examination confirmed that R-0 resection had been achieved. After 18 months of the operation, computed tomography(CT) showed a local recurrence of the tumor in the posterior segmental branch of the intrahepatic bile duct with the portal vein invasion. The recurrent tumor was localized only in the region and we decided to operate again. The tumor was resected with the posterior segment, the portal vein and the hepaticojejunosotomy. The patient had an uncomplicated postoperative recovery and was discharged home. Conclusion: We successfully performed re-hepatectomy for a local recurrence of hilar cholangiocarcinoma. As far as we know, such a case has not been reported. In the first operation, we chose not extended right hepatectomy nor extended left hepatectomy but central bisegmentectomy and as a result, remnant liver volume was spared. As a result, she could undergo curative major hepatectomy again.

Reconstruction of the middle hepatic vein using a vein graft from the resected portion of the liver

BackgroundThe middle hepatic veins are often infiltrated by intrahepatic cholangiocarcinoma. Reconstruction of the hepatic vein plays a critical role in preserving more of the residual liver volume and reducing the risk of postoperative liver failure in extreme hepatectomy. We here report a novel way to reconstruct middle hepatic vein by using vessel grafts from wasted liver.Case presentationCase 1: A 64-year-old man was diagnosed with intrahepatic cholangiocarcinoma. The bifurcation and left branch of the portal vein were stenosed, and the root of the middle hepatic vein was infiltrated by the tumor. An extended left hepatectomy was performed, the portal vein was resected and reconstructed, and the middle hepatic vein was reconstructed by anastomosing the proximal left hepatic vein to the distal middle hepatic vein. Case 2: A 69-year-old woman was diagnosed with intrahepatic cholangiocarcinoma. The tumor was located in the left lobe of the liver and the left and middle hepatic veins were infiltrated by the tumor. An extended left hepatectomy was performed, and the left portal vein was used as a vein graft to reconstruct the middle hepatic vein. Both of the two patients’ postoperative ultrasound showed vessel graft patency.ConclusionUsing a vein graft from the resected portion of the liver to reconstruct the middle hepatic vein was a useful technique and showed good result.

Robotic Resection of a Central Liver Solitary Fibrous Tumor (with Video)

BackgroundSolitary fibrous tumor is a mesenchymal tumor rare in liver parenchyma 1 but must be considered as a differential diagnosis of a single large hepatic mass. Surgical resection is the treatment because of its potential malignancy, and previous interventions reported were open hepatectomy 2. Robotic assets could improve accessibility for difficult liver resection 3. We present the video of a robotic left hepatectomy extended to caudate lobe and median hepatic vein for central liver tumor. MethodsA central liver tumor was incidentally detected during abdominal ultrasonography in a 30-year-old man with no medical history. Laboratory tests were normal. CT scan and MRI revealed a solid mass measuring 9 cm involving segments I–IV–VIII and median/left hepatic veins. Percutaneous biopsy confirmed diagnosis of benign liver solitary fibrous tumor. Surgical resection by left hepatectomy extended to segment 1 and median hepatic vein was planned. ResultsDa Vinci X system was docked from patient’s head. Four robotic ports were placed in right hypochondrium. Two laparoscopic ports were placed for the second surgeon. Extended left hepatectomy was performed with hilar approach. Parenchymal transection was led on the right side of median hepatic vein using laparoscopic ultrasonic dissector and robotic irrigated bipolar. Segment 1 was released with a mediocaudal approach. Procedure was facilitated by good exposure of operative field with arm 4, stable vision, articulated instrumentation and a “4-hand parenchymal dissection”. ConclusionMinimal invasive resection of liver solitary fibrous tumor seems safe and feasible. Because of its advantages compared with laparoscopy, robotic approach could improve accessibility to central tumors liver resection.

Analysis of pre and postoperative inflammatory scores in curative resections for colorectal cancer liver metastasis

Background: Inflammatory scores (neutrophil lymphocyte ratio NLR, platelet lymphocyte ratio PLR, Glasgow prognostic score GPS, prognostic nutritional index PNI, lymphocyte monocyte ratio LMR) predict oncologic survival after colorectal cancer liver metastasis (CRCLm). However, there are few studies analyzing their association with postoperative morbidity. Patients & Methods: Retrospective analysis of our CRCLm database from January 2014 to June 2018 at Valladolid University Clinic Hospital (Spain). Endpoints: morbidity according to Clavien-Dindo (CD) Classification, infectious complications, transfusion, length of stay (LOS). Study variables: aforementioned inflammatory scores (preoperative and postoperative day 1) and patient´s comorbidities. Results: 49 patients (males: 69.4%, age: 65.4±11.03years). Median number of resected CRCLm: 2 (IQR=1-3). Total tumor diameter (Σ): 34.8±19.6mm. Liver resection: segmentectomy (32.7%), metastasectomy (24.5%), left hepatectomy (18.4%), right hepatectomy (14.3%), left lateral sectionectomy (6.1%), right and left extended hepatectomy (2%), laparoscopic procedures: 2 cases (4.1%, no conversion). Additional intraoperative radiofrequency ablation: 6.1%. Neoadjuvant chemotherapy: 51%. Median LOS: 8(IQR= 6.5-11.5days). Comorbidities: arterial hypertension (12.2%), dyslipidemia (28.6%), smoking (18.4%), cardiovascular diseases (14.3%), diabetes mellitus (12.2%), alcohol consumption (8.2%), chronic obstructive pulmonary disease (4.1%). Postoperative complications: global (53.1%), infectious (24.5%), CD≥III (16.3%). 6.1% of patients required reoperation. No association between age, comorbidities, ASA and postoperative complications. Patients with pGPS=0 and pGPS=1 presented a median LOS of 9.2±6.4days and 22±8.2days respectively (p=0.001). Overall morbidity, CD≥III and reoperation rate was higher among patients with preoperative GPS(pGPS)=1 vs. pGPS=0(100% vs. 48.9%, p=0.05, 50% vs. 13.3%, p=0.05, and 50% vs 2.2%, p=0.015, respectively). 59% of patients with postoperative GPS(poGPS)=2 presented complications vs. 30% of patients with poGPS=1(p=0.1). Patients suffering overall complications had lower postoperative mean albumin values(2.93±0.46 vs. 3.39±0.42g/dL, p=0.001) and lower postoperative PNI(29.32±4.6 vs. 33.93±4.25, p=0.001). Conclusions: The pGPS could be a good predictor of complications following resection of CRCLm. Patients with complications had lower postoperative albumin and PNI values.

A man with repeated cholangitis

A 67-year-old man, with a past medical history of remarkable left intrahepatic biliary stones and recurrent episodes of acute cholangitis, presented to our hospital with low-grade fever and epigastric dull aching followed by tea-colored urine for 1 week. Initial laboratory data were as follows: Hb 11.5 g/dL, WBC (white blood count) 17 700/mm3, CRP (C-Reactive Protein) 25.13 mg/dL, AST/ALT (aspartate transaminase/alanine transaminase) 39/45 IU/L, bilirubin (T/D) 7.5/4.6 mg/dL, alkaline phosphatase 596 IU/L, CEA (carcinoembryonic antigen) 1.92 ng/mL, AFP (Alpha-FetoProtein) 4.10 ng/mL, PSA (prostate specific antigen) 5.57 ng/mL, and CA 19-9 (Carbohydrate Antigen 19-9) 92.56 U/mL. Abdominal computed tomography demonstrated a new-onset mass lesion (10 cm in diameter) occupying the left lobe of liver. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) of the liver demonstrated a 10 cm liver mass with dilatation of adjacent IHDs (intrahepatic duct) in the left lobe (mainly in segment 4), indicating a malignant neoplasm (Figure 1). The preoperative diagnosis was ICC according to his clinical presentation and radiological images. He received an extended left hepatectomy after a thorough preoperative evaluation, including the ICG (Indocyanine green) test. The histopathological examination demonstrated intraductal papillary neoplasm of bile duct (IPNB) with low-grade dysplasia and marked chronic inflammation (Figure 2). His postoperative course was uneventful, and he was discharged 10 days after the operation. IPNB, formerly named biliary papillomatosis, is a rare biliary epithelial tumor with an exophytic nature exhibiting a papillary mass within the bile duct lumen and with a prominent intraductal growth pattern. It has been considered as a precursor lesion of invasive cholangiocarcinoma. The grade of intraepithelial neoplasia is defined as either low-intermediate, high, or invasive carcinoma according the World Health Organization's 2010 classification system.1 The clinical picture of IPNB consists of recurrent colicky abdominal pain and repeated episodes of acute cholangitis with fever and jaundice due to partial or intermittent biliary obstruction.2 Common radiological findings for IPNB are bile duct dilatation or intraductal masses, and liver solid tumors are rarely seen. It is difficult to distinguish IPNB from other inflammatory and neoplastic lesions based on radiological appearance alone, including DCE-MRI of liver.3 Patients with IPNB should be considered for treatment because of the high risk of recurrent cholangitis and malignant transformation. Resection is the treatment of choice when IPNB is localized according to preoperative imaging workup. The overall prognosis is better in patients with IPNB than ICC, and long-term survival is anticipated after curative resection.4 The author declares no conflict of interest.

Extended left hepatectomy with temporary porto-caval shunt under total hepatic vascular exclusion and liver cooling

Background: We report the case of a 79-year-old patient with voluminous cholangiocarcinoma that was located in the left liver extended to segment V. A left extended hepatectomy is planned, under temporary porto-caval shunt (TPCS) and Liver Cooling (LC) Methods: The patient was operated on 5 days before from left portal vein ligation. The first step is preparing for TPCS: the right suprahepatic and the trunk of the main and left suprahepatic veins are controlled and the liver is fully mobilized to expose and control the infra and suprahepatic inferior vena cava with a tape. The pedicle is prepared dissecting the portal vein independently from the artery and bile duct. Results: The second step is to realize porto-caval shunt: the graft is sutures between the inferior vena cava and the main trunk of the portal vein. The film reports step by step this operative procedure, until the cannulation of the portal vein. The third step starts with the extended left hepatectomy. The transaction is realized using conventional bipolar electrocautery and ultrasonic dissection. The mains segmental pedicles were controlled using ligation, in particular the pedicle of segment VIII that must be preserved. Conclusion: Liver is rewarmed, cannula is removed. The interest of this film is: i) the realisation of the venous shunt using a vascular graft and ii) the major hepatic resection, which can be managed safely, taking the time to attentively perform a meticulous haemostasis, thanks to the temporary portacaval shunt.

Extended left hepatectomy with temporary porto-caval shunt under total hepatic vascular exclusion and liver cooling

Extended left hepatectomy with temporary porto-caval shunt under total hepatic vascular exclusion and liver cooling

Extended left hepatectomy and hepatic vein reconstruction with insitu hypothermic perfusion and Veno-venous bypass for intrahepatic cholangiocarcinoma

Extended left hepatectomy and hepatic vein reconstruction with insitu hypothermic perfusion and Veno-venous bypass for intrahepatic cholangiocarcinoma

Extended left hepatectomy and hepatic vein reconstruction with insitu hypothermic perfusion and veno-venous bypass for intrahepatic cholangiocarcinoma

Extended left hepatectomy and hepatic vein reconstruction with insitu hypothermic perfusion and veno-venous bypass for intrahepatic cholangiocarcinoma