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Background Although laparoscopic liver resection has become the standard for minor resections, evidence is lacking for more complex resections such as the right posterior sectionectomy (RPS). We aimed to compare surgical outcomes between laparoscopic (LRPS) and open right posterior sectionectomy (ORPS). Methods An international multicenter retrospective study comparing patients undergoing LRPS or ORPS (January 2007—December 2018) was performed. Patients were matched based on propensity scores in a 1:1 ratio. Primary endpoint was major complication rate defined as Accordion ≥ 3 grade. Secondary endpoints included blood loss, length of hospital stay (LOS) and resection status. A sensitivity analysis was done excluding the first 10 LRPS patients of each center to correct for the learning curve. Additionally, possible risk factors were explored for operative time, blood loss and LOS. Results Overall, 399 patients were included from 9 centers from 6 European countries of which 150 LRPS could be matched to 150 ORPS. LRPS was associated with a shorter operative time [235 (195–285) vs. 247 min (195–315) p = 0.004], less blood loss [260 (188–400) vs. 400 mL (280–550) p = 0.009] and a shorter LOS [5 (4–7) vs. 8 days (6–10), p = 0.002]. Major complication rate [n = 8 (5.3%) vs. n = 9 (6.0%) p = 1.00] and R0 resection rate [144 (96.0%) vs. 141 (94.0%), p = 0.607] did not differ between LRPS and ORPS, respectively. The sensitivity analysis showed similar findings in the previous mentioned outcomes. In multivariable regression analysis blood loss was significantly associated with the open approach, higher ASA classification and malignancy as diagnosis. For LOS this was the open approach and a malignancy. Conclusion This international multicenter propensity score-matched study showed an advantage in favor of LRPS in selected patients as compared to ORPS in terms of operative time, blood loss and LOS without differences in major complications and R0 resection rate.

Objective Advances in surface-based morphometric methods have allowed researchers to separate cortical volume into cortical thickness (CTh) and surface area (SA). Although CTh alterations in major depressive disorder (MDD) have been observed in numerous studies, few studies have described significant SA alterations. Our study aimed to measure patients’ SAs and to compare it with their CTh to examine whether SA exhibits alteration patterns that differ from those of CTh in drug-naïve patients with MDD.Methods A total of 71 drug-naïve MDD patients and 111 healthy controls underwent structural magnetic resonance imaging, and SA and CTh were analyzed between the groups.Results We found a smaller SA in the left superior occipital gyrus (L-SOG) in drug-naïve patients with MDD. In the CTh analysis, the bilateral fusiform gyrus, left middle occipital gyrus, left temporal superior gyrus, and right posterior cingulate showed thinner cortices in patients with MDD, while the CTh of the bilateral SOG, right straight gyrus, right posterior cingulate, and left lingual gyrus were increased.Conclusion Compared with the bilateral occipito-temporal changes in CTh, SA alterations in patients with MDD were confined to the L-SOG. These findings may improve our understanding of the neurobiological mechanisms of SA alteration in relation to MDD.

Background Attention deficit hyperactivity disorder (ADHD) is an early-onset neurodevelopmental disorder that can extend into adulthood with multiple reported neuroimaging abnormalities. The focus of this research was to assess white matter impairments in ADHD children’s fathers with and without potential adult ADHD to see if these differences are connected with the persistence of ADHD into adulthood. Results The occurrence rate of the potential adult ADHD diagnosis among fathers of children with ADHD was 60%. There were statistically significant differences between fathers with ADHD and the non-ADHD population, due to the fact that the mean FA of the left superior corona radiata and the right posterior corona radiata were lower in the ADHD group than in the non-ADHD group, while the FA of the ADHD group was significantly greater than that of the non-ADHD group in terms of the left and right anterior thalamic radiations, the right superior longitudinal fasciculus and the left anterior corona radiata. Conclusions We observed an increased prevalence of ADHD in fathers of children diagnosed with ADHD. Fathers with potential adult ADHD have a variety of white matter abnormalities that reflect the neurobiological basis of ADHD, even in sub-threshold cases. This may provide insight into the neuroanatomical locations associated with the maintenance of ADHD throughout adulthood.

The purpose of this study was to determine the prevalence and to investigate the morphology of the sulcus of the caudate process in a Greek population, along with a systematic review and meta-analysis of the literature. Overall, 103 consecutive patients undergoing laparoscopic cholecystectomy were included in the analysis. The sulcus was present in 91% and three morphological variants were identified (groove 69%, slit 21% and scar 10%). The sulcus had a horizontal course in 90% of patients and a mean length of 25 ± 13 mm. The meta-analysis included 27 surgical and 11 cadaveric studies with 6661 cases in total. The pooled prevalence of the sulcus was 80% and did not differ significantly among various geographical regions. Concerning sulcus subtypes, the binary "open/fused" classification was used to unify the heterogeneous data. The "open" type was more frequent than the "fused" (64.5% vs 35.5%). A horizontal course was observed in 53.5% and an oblique in 45.7%. The sulcus contained the right portal pedicle in 38%, the right posterior portal pedicle in 37%, and the right posteroinferior pedicle in 23.5%. In conclusion, the sulcus of the caudate process is a very helpful anatomical landmark in hepatectomy and laparoscopic cholecystectomy and can be identified in the majority of patients. However, various classifications for the morphological variants and diverse terminology cause discrepancy in the literature and create the need for a single classification system. The proposed 3-tier classification (groove, slit, scar) is simple and easy to remember and avoids ambiguous nomenclature.

Posterior retroperitoneoscopic adrenalectomy (PRA) allows the surgeon to approach the adrenal gland through the back rather than the more traditional laparoscopic transabdominal adrenalectomy (LTA) approach. This technique was popularized in Germany but is being used increasingly throughout the United States. Our institution was one of the early adopters of this technique in the US and we present such an operation here.

Background This study aimed to evaluate the effect of mandibular complete dentures relining using soft relining material on the distribution of various occlusal forces using T-Scan system. Fifty completely edentulous patients having their conventional complete dentures earlier fabricated and utilized were selected for this study. Patients were controlled diabetics, characterized by having their residual alveolar ridges moderately developed and lined with firm mucoperiosteum. Mandibular complete dentures were relined with soft denture liner and T-Scan device was used for occlusal force distribution measurement prior to denture relining and three months thereafter the relinning procedure. Results Comparison between occlusal forces percentages before and after denture relining revealed that occlusal forces percentages was significantly lower after denture relining in anterior area, significantly higher after denture relining in right posterior area, where it was insignificantly higher after relining in left posterior area. Conclusions Our findings revealed that the use of soft denture liner for mandibular complete denture relining significantly improved the occlusal load distribution. Clinical trial registration Trial registration NCT, NCT04701970. Registered 23/11/2020—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04701970

Objective: The present study estimated the prevalence of gingival recession (its severity and distribution) and assessed the association of potential risk indicators with the occurrence of gingival recession in Qena governorate, Egypt. Subject and methods: A representative sample of 1959 patients aged from 18 -90 years old (984 males and 975 females) from different areas in Qena governorate, Egypt were examined. A descriptive questionnaire was prepared for the examinations and full personal data were recorded. Results : The prevalence of gingival recession was 32.8%; Class I recession was (24.2%) followed by Classes II, III and IV (7.2, 1.3 and 0.1%, respectively). The most affected quadrants were the lower left quadrant while the least affected quadrant was the upper right quadrant. The most affected teeth were lower anterior teeth while The least commonly affected teeth were lower right posterior teeth. Conclusion: Prevalence of gingival recession showed more frequently in males than in females. Gingival recession was found to be more common in mandibular arch than maxillary. Lower anterior teeth than posterior ones and Left side of the arch was more commonly affected. This is a preliminary basis toward establishing a complete epidemiological study regarding the prevalence, severity as well as manifestations of oral diseases in Egypt. Hopefully, this help toward planning effective, preventive as well as therapeutic measures in this regard.

Spinal pial arteriovenous fistulas (spAVFs) are believed to be congenital lesions, and the development of a de novo spAVF has not been previously described. A 49-year-old female with a childhood history of vascular malformation–induced right lower-extremity hypertrophy presented in 2004 with progressive pain in her right posterior thigh and outer foot. Workup revealed 3 separate type IV spAVFs, which were treated by combined embolization and resection, with final conventional angiography showing no residual spinal vascular lesion in 2005. Ten years later, the patient returned with new right lower-extremity weakness, perineal pain, and left plantar foot numbness. Repeat spinal angiography demonstrated 2 de novo intertwined conus medullaris spAVFs.

This is a case report of a spontaneous retinal pigment epithelial (RPE) rip in a 64-year-old woman who presented with progressive, painless, blurring of vision in her right eye for 2 weeks. Her vision was 6/60 in the right eye and 6/6 in the left eye. On fundoscopy, there was a large depigmented area over the right posterior pole. A large area of RPE rip involving the fovea was revealed via optical coherence tomography and angiogram. Spontaneous RPE rip is a rare manifestation. However, when the fovea is involved the visual prognosis is poor. This article aims to highlight the vital role of multimodal imaging in aiding the diagnosis of RPE rips or tears.

BACKGROUND: Uncinate process dissection is a key step in minimally invasive pancreaticoduodenectomy (MIPD), including laparoscopic and robotic procedures, which increase the intraoperative blood loss and operative time and decrease the R0 resection rate if improperly handled. However, few studies have reported the operative skills in detail. METHODS: We performed uncinate process dissection using a combination of the anterior superior mesenteric vein (SMV)-first approach and the right posterior superior mesenteric artery (SMA)-first approach in MIPD for 138 patients with periampullary tumors between March 2017 and October 2019. The demographic and perioperative data of all the patients were collected to evaluate the efficacy of this method. RESULTS: All patients underwent an uneventful operation. An assistant incision was performed to separate extensive adhesion between the tumor and the SMV in 3 patients. The combined approach had a notably shorter operation time and resection time, less intraoperative blood loss and a shorter postoperative hospital stay than the traditional approach (P0.05). There were no deaths during the perioperative period. CONCLUSIONS: The combination of the anterior SMV-first approach and the right posterior SMA-first approach is a safe and feasible technique for uncinate process dissection in MIPD.

Laparoscopic segment 7 segmentectomy and segment 6–7 bisegmentectomy are challenging resections because of the posterior position and the lack of landmarks. The anatomy of the right posterior Glissonean pedicle and the caudal view of laparoscopy make such resections suitable for the Glissonean pedicle-first approach. The study population included all consecutive patients treated with laparoscopic liver resection from August 2019 to February 2020. The approach is based on the ultrasonographic identification of the right posterior or segmental pedicle from the dorsal side of the liver after complete mobilization. The pedicle of interest is isolated through mini-hepatotomy and clamped. The segment anatomy is defined by ischemia. The transection starts from the ventral side, close to the right hepatic vein that is exposed and followed craniocaudally. Ten patients underwent anatomical laparoscopic resection of right posterolateral segments. There were 7 colorectal liver metastases, 2 hepatocellular carcinoma, and 1 biliary cysto-adenoma. Five patients underwent Sg7 resection, one patient underwent a Sg7 subsegmentectomy, and 4 underwent Sg6-7 bisegmentectomy. The Glissonean pedicle-first approach was feasible in eight patients. The craniocaudal approach to the RHV was feasible in six patients, not indicated in three cases and was abandoned in one patient for technical difficulty. There was no operative morbidity or mortality. Median post-operative hospital stay was 5 days. The Glissonean pedicle-first approach is safe and effective for laparoscopic anatomic resections of the right posterior sector. The craniocaudal approach to right hepatic vein from the ventral side is a convenient procedure to follow the segmental anatomy deep in the parenchyma.

We report a rare case of osteochondromatosis of the posterior ankle extra-articular space with a longitudinal tear of flexor hallucis longus (FHL). A 77-year-old woman was referred to our hospital with an approximately 4-year history of pain and swelling in the right posterior ankle joint without obvious trauma. The pain had worsened in the previous 2 years. On presentation, she had tenderness at the posteromedial and posterolateral ankle. Imaging revealed several ossified loose bodies in the posterior ankle extra-articular space. We removed the loose bodies, performed tenosynovectomy around the FHL, and released the FHL tendon using a posterior arthroscopic technique via standard posterolateral and posteromedial portals. A longitudinal tear and fibrillation were detected in the FHL. The patient was able to return to her daily activities approximately 3 weeks after surgery. At the 1-year follow-up visit, she continued to have minor discomfort and slight swelling on the posteromedial aspect of the right ankle but had no recurrence of the ossified loose bodies. To our knowledge, this is the first report of osteochondromatosis of the posterior ankle extra-articular space with a longitudinal tear of the FHL that was treated by removal of loose bodies, tenosynovectomy around the FHL, and release of the FHL tendon via posterior ankle arthroscopy.

A typical bile duct branching patterns represent one of the major causes of bile duct injury (BDI) during laparoscopic cholecystectomy (LC). The most common classified variations of bile duct branching, involve the right posterior sectoral duct (RPSD) and its joining with the right anterior or left hepatic duct. Variant bile duct anatomy can rarely be extremely complex and unclassified. This report describes an extremely rare case of an isolated injury to an aberrant right hepatic duct formed by the joining of ducts from segments V, VII, and VIII draining into the cystic duct (cysticohepatic duct) during LC, associated with an inferior RPSD opening to left hepatic duct. Detailed evaluation of both endoscopic and magnetic cholangiograms established the diagnosis. Bile duct injury was subsequently managed surgically by a demanding Roux-en-Y hepaticojejunostomy. This extremely rare case aims to serve as a useful reminder of the consistent inconsistency of biliary anatomy, alerting surgeons to beware of variant bile duct branching patterns during open or LC that constitute a dreadful pitfall for severe and life-threatening bile duct injuries.

To study the variations of the right branch of the hepatic portal vein in children. A total of 810 children’s abdominal CT images were reconstructed with three-dimensional (3D) simulation software, Variations of the right branch of the hepatic portal vein were analyzed and classified. The most common anatomy (type A) was seen in 355 patients (43.83%). Trifurcation in the right anterior portal vein (type B) variation was seen in 250 cases (30.86%). The right posterior portal vein arched without obvious branching (type C) was seen in 71 cases (8.77%). There were 134 special variants (16.54%) named type D, including 14 cases (1.73%) with the right anterior branch in four sub-branches, 13 cases (1.60%) in one trunk and multiple sub-branches, 92 cases (11.36%) originating from the left trunk of the portal vein, and 15 cases (1.85%) with the VI segment of the portal vein originating from the right anterior branch of the portal vein. Variations in the right branch of the hepatic portal vein seems to be very frequent. Recognition of such variations is important in the preoperative evaluation of children with surgery planned, because these variations may have implications for anatomy-guided liver resection and for planning the operative approach.

Calcifying epithelial odontogenic tumor is a rare benign odontogenic tumor which accounts for approximately 1% of the entire odontogenic tumor. It was firstly described by Pindborg, and thus, is also referred to as the “Pindborg tumor”. Histologically, Pindborg tumor consists of three distinct histological compo­nents: sheets of polyhedral epithelial cells, amyloid like deposits, and calcifications. This case report describes a case of Calcifying epithelial odontogenic tumor in 26 years old female patient presented with the swelling in right posterior region of mandible. Taking into account of the aggressive nature of the lesion segmental resection of the mandible followed by reconstruction was planned for treatment. This case report highlights the importance of appropriate clinical, radiographical and histological correlation for the correct diagnosis and treatment of Pindborg tumor.

Background Alzheimer's disease (AD) and dementia with Lewy bodies (DLB) are often misdiagnosed with each other because of similar symptoms including progressive memory loss. The metabolic network topology that describes inter-regional metabolic connections can be generated using fluorodeoxyglucose positron emission tomography (FDG-PET) data with the graph-theoretical method. We hypothesized that different metabolic connectivity underlies the symptoms of AD patients, DLB patients, and cognitively normal (CN) individuals. Objective This study aimed to generate metabolic connectivity using FDG-PET data and assess the network topology to differentiate AD patients, DLB patients, and CN individuals. Methods This study included 45 AD patients, 18 DLB patients, and 142 CN controls. We analyzed FDG-PET data using the graph-theoretical method and generated the network topology in AD patients, DLB patients, and CN individuals. We statistically assessed the topology with global and nodal parameters. Results The whole metabolic network was preserved in CN; however, diffusely decreased connection was found in AD and partially but more deeply decreased connection was observed in DLB. The metabolic topology revealed that the right posterior cingulate and the left transverse temporal gyrus were significantly different between AD and DLB. Conclusion The present findings indicate that metabolic connectivity decreased in both AD and DLB, compared with CN. DLB was characterized restricted but deeper stereotyped network disruption compared with AD. The right posterior cingulate and the left transverse temporal gyrus are significant regions in the metabolic connectivity for differentiating AD from DLB.

The aim of our research is to perform a retrospective analysis of all cases involving biliary complications after liver transplantation in two transplant centers of Kazakhstan. In the period from December 2011 and December 2019, 106 adult patients underwent LT at Syzganov's National Scientific Center of Surgery and City Clinical Hospital №7, Almaty, Kazakhstan. Eighty-nine (84%) patients underwent living donor liver transplantation (LDLT) from an adult donor, while 17 (16%) patients underwent deceased donor liver transplantation. The graft types were as follows: whole liver (n=17; 16%), right lobe (n=82; 77.3%), left lobe (n=6; 5.6%), and right posterior section (n=1; 0.9%). Duct-to-duct anastomosis was performed in 102 cases, the types of which were as follows single duct-to-duct anastomosis (n=95; 93.1%), double duct-to-duct anastomosis (n=5; 4.9%), combined-type anastomosis (duct-to-duct anastomosis and roux-en-Y hepaticojejunostomy [n=2; 1.9%]). Roux-en-Y hepaticojejunostomy was performed in 3 cases. A biliary splint was used in 53 (52%) cases; biliary splints were not used in 49 (48%) cases. Preoperative and intraoperative methods of investigating (MRC, IOC) the biliary tracts can reveal the types of biliary tracts and are useful for planning the type of biliary reconstruction. Various types of biliary reconstruction are associated with a high risk of biliary complications after liver transplantation. Biliary splinting in duct-to-duct anastomosis reduces the incidence of biliary complications.

Objective To determine the correlation between portal vein diameter and spleen size (craniocaudal). Methodology The study was conducted at the University Ultrasound Clinic, The University of Lahore, Lahore Pakistan from 1st January to 1st July 2013. All the individuals who referred for abdominal sonographic examination, including male, female, older and younger were conveniently included in the study, voluntarily, irrespective of the disease state. Ultrasonographic measurements of the caudocranial length of the spleen and portal vein were carried out on all of the one thousand subjects. The subject position for spleen was supine or right posterior oblique during suspended inspiration and right anterior oblique position for portal vein diameter with quiet respiration. The correlation between the splenic length and portal vein diameter was evaluated. Result A total of 1000 subjects; 36.9% females and 63.1% males aged from 4 to 79 years. The mean splenic length was 10.29 ± 1.89 cm. The mean portal vein diameter was 10.27 ± 1.78 mm. A statistically significant correlation was found between the spleen size and portal vein diameter; the Pearson correlation was significant at the 0.01 level. Conclusion Portal vein diameter is directly correlated to splenic caudocranial length. A regression formula was developed to measure the splenic length from the calculation of portal vein diameter.

Background The aim of this study was to assess the prevalence of biliary anatomical variants using 3-T MR cholangiography (MRC) with its impact in reduction of the complication of hepatobiliary surgical techniques. Results MRC was applied to 120 subjects (24 potential liver donors and 96 volunteers) and the right posterior hepatic duct insertion was documented, and accordingly, the biliary variants were classified based on Huang classification (Huang et al, Transplant Proc 28: 1669–1670, 1996). Biliary anatomic variants were divided based on Huang classification: Huang A1, 65.83% (n = 79); Huang A2, 11.67% (n = 14); Huang A3, 13.3% (n = 16); Huang A4, 7.5% (n = 9); and Huang A5, 1.67% (n = 2). The total frequency for A2, A3, A4, and A5 was 34.17% (n = 41). The distance between RPHD insertion and the junction of right and left hepatic ducts (L) was measured, and Huang A1 cases were then subtyped into S1 subtype (L > 1 cm) and S2 subtype (L ≤ 1 cm). We had 52 subjects with subtype S1 (43.33%) and 27 subjects with subtype S2 (22.5%). Twenty-three subjects had bile duct exploration or intraoperative cholangiograms and showed Huang type A1 in 14 (60.87%), type A2 in 3 (13.05%), and type A3 in 6 (26.08%). Twenty-two (95.65%) had the same classification in MRC and intraoperative while only one case (4.35%) was considered as A2 at MRC but the intraoperative classification was Huang A3, which was attributed to the insertion of the RPHD insertion at the distal end of the left hepatic duct. Conclusion MRC is an accurate tool for biliary tract mapping before hepatobiliary surgery to provide excellent identification of biliary variants which can reduce the incidence of biliary complications.

Soft tissue myofibromas of the head and neck are relatively common lesions diagnosed within the first two decades of life; however, these myofibromas are rarely found to affect the jaw bones. Myofibromas that do develop within the bone are referred to as intraosseous myofibromas (IM). A thorough search and review of the literature has found only five cases of IM impacting the mandible of an adult patient. The current case report describes a myofibroma impacting the right posterior mandible in a 44-year-old male patient with no previous history of pathology or surgery within the affected area. Histologic examination of the incisional biopsy specimen revealed a proliferation of spindle cells, and the spindle cells showed positivity for SMA on immunohistochemical staining supporting the diagnosis of myofibroma. The final pathology results of the subsequent composite resection of the lesion yielded a 1.5cm myofibroma that was < 1mm from the nearest bone/soft tissue edge; the resection margin was uninvolved by tumor. The purpose of this case report is to present the sixth case of IM of the mandible of an adult patient and to review the pertinent radiographic and clinical features, and necessary methods for diagnosis and treatment of this rare entity.

Only 0.12% to 2% of diagnosed hernias are Spigelian type. Even less frequently encountered—Grynfeltt-Lesshaft hernias—hernias have unknown incidence. A Spigelian hernia is encountered along the Spigelian fascia and Grynfeltt-Lesshaft hernias are bounded by the superior lumbar triangle. These unique hernias can both be intermuscular, given their anatomical borders which allow concealment and preclusion of accurate diagnosis. Here, an 86-year-old male presented with symptoms consistent with small bowel obstruction. On physical exam, a right lower quadrant hernia and right posterior flank mass were appreciated. Computed tomography revealed obstruction secondary to bowel incarceration within Spigelian hernia and additional Grynfeltt-Lesshaft hernia. The patient underwent reduction and repair of Spigelian hernia with synthetic mesh, while repair of asymptomatic hernia was deferred. These unusual hernias are difficult to distinguish, given their negligible occurrence and unreliable exam findings. Clinicians must remain cognizant of their features to aid in diagnosis and mitigate potential sequelae.

Aberrant insertion of the right posterior sectoral duct is a particularly hazardous variation of biliary anatomy which makes it prone to injury during laparoscopic cholecystectomy. Such injuries are challenging to manage, as multiple therapeutic options are available with no clear consensus in the literature for an optimal approach. Options include conservative management, intraoperative ligation of the injured duct, Roux-en-Y reconstruction and segmental liver resection. Most cases in the literature advocate for nonoperative management or hepaticojejunostomy. We present an unusual case of aberrant right posterior sectoral duct injury in which neither of these approaches was viable, necessitating a bi-segmental liver resection.

No study has reported a unilateral localized cerebral lesion of the posterior insula bilaterally reducing noxious stimuli perception. A 57-year-old man with an infarct involving the right posterior insula presented with reduced somatosensory response in the upper and lower left extremities. Furthermore, there was a reduced response to noxious stimulation in the right upper and lower limbs. We noted reductions in pain, noxious heat and cold perceptions, and sensitivity to increasing temperature. Other somatic sensations, including non-noxious temperatures, remained intact in the right upper and lower extremities. These findings in our patient with a unilateral insular lesion indicated a bilaterally reduced perception of noxious stimulation.

Background Minimally invasive right posterior sectionectomy (RPS) is a technically challenging procedure. This study was designed to determine outcomes following robotic RPS (R-RPS) and laparoscopic RPS (L-RPS). Methods An international multicentre retrospective analysis of patients undergoing R-RPS versus those who had purely L-RPS at 21 centres from 2010 to 2019 was performed. Patient demographics, perioperative parameters, and postoperative outcomes were analysed retrospectively from a central database. Propensity score matching (PSM) was performed, with analysis of 1 : 2 and 1 : 1 matched cohorts. Results Three-hundred and forty patients, including 96 who underwent R-RPS and 244 who had L-RPS, met the study criteria and were included. The median operating time was 295 minutes and there were 25 (7.4 per cent) open conversions. Ninety-seven (28.5 per cent) patients had cirrhosis and 56 (16.5 per cent) patients required blood transfusion. Overall postoperative morbidity rate was 22.1 per cent and major morbidity rate was 6.8 per cent. The median postoperative stay was 6 days. After 1 : 1 matching of 88 R-RPS and L-RPS patients, median (i.q.r.) blood loss (200 (100–400) versus 450 (200–900) ml, respectively; P 500 ml; P = 0.001), need for intraoperative blood transfusion (10.2 versus 23.9 per cent, respectively; P = 0.014), and open conversion rate (2.3 versus 11.4 per cent, respectively; P = 0.016) were lower in the R-RPS group. Similar results were found in the 1 : 2 matched groups (66 R-RPS versus 132 L-RPS patients). Conclusion R-RPS and L-RPS can be performed in expert centres with good outcomes in well selected patients. R-RPS was associated with reduced blood loss and lower open conversion rates than L-RPS.

Right posterior section (RPS) graft for living donor liver transplantation (LDLT) is an alternative graft in a live liver donor with insufficient remnant left lobe volume and portal vein anomaly.(1,2) In recent decades, laparoscopic liver resection (LLR) has been widely adopted by hepatobiliary surgeons, and the indication for LLR have expanded to donor hepatectomy.(3,4) Laparoscopic-approach donor surgery would be ideal for liver donation in healthy individuals, due to the fast return to normal life and satisfaction with the incisional scar. However, there have been no reports regarding laparoscopic donor hepatectomy for RPS graft. Herein, we report surgical outcomes and techniques of pure laparoscopic donor right posterior sectionectomy (PLDRPS) for LDLT. The institutional review boards of our center (number 2019-03-080) approved this study.

Background Laparoscopic central bisectionectomy (Couinaud's segment IV, V, and VIII) needs exposure of the RHV and MHV on the surface of the remnant and the resecting side, respectively. Avoiding venous injury is mandatory and laparoscopy-specific cranio-caudal approach to hepatic veins might be helpful (Ueno et al., 2020) [1]. We present this procedure in performing laparoscopic central bisectionectomy. Patient A 45-year-old female was admitted to our hospital with a 6 cm HCC in the segment VIII and IV. Her comorbid disease was non-cirrhotic HBV hepatitis (Child-Pugh grade A) and diabetes (untreated). Method After cholecystectomy, G4 branches were dissected and cut by extra- or intra-hepatic approach. Hilar plate was dissected and the Gant was encircled and occluded by a vascular clip. Afterwards, exposure of the MHV was started at its root on IVC (Monden et al., 2020; Kim, 2019) [2,3] and extended in cranio-caudal direction (Ueno et al., 2020) [1]. After sufficient space was obtained around the Gant, the Gant and the MHV were cut. Parenchymal transection between right anterior and right posterior sections was also started form the root of the RHV to its cranio-caudal direction. Liver resection was finished with full exposure of the RHV. Results The operating time was 380 minutes, and the blood loss volume was 30 ml. Postoperative CT image showed exposure of the RHV and umbilical portion of Glissonean branch, and no fluid retention. Conclusion Laparoscopy-specific cranio-caudal approach to hepatic veins may be useful to avoid split injury of venous branches (Honda et al., 2020) [4], especially if the hepatectomy requires complete exposure of hepatic vein, such as central bisectionectomy.

Background In living donor liver transplantation (LDLT) for patients with Budd‒Chiari syndrome (BCS), there are several concerns about reconstruction of the inferior vena cava (IVC) and hepatic veins. Herein, we report the case of a patient with BCS who underwent LDLT with right posterior segment graft (RPSG) and patch plasty for reconstruction of the hepatic venous outflow, using the patient’s own superficial femoral vein (SFV). Case presentation A 19-year-old man, who was diagnosed with primary BCS, underwent LDLT. His main hepatic veins were totally obstructed, and membranous stenosis was seen in the IVC. The LDLT donor was his mother; however, liver volumetric analysis showed that only her RPSG was appropriate. In the recipient surgery, 16 cm of the left SFV was harvested and was cut longitudinally and opened. The right hepatic vein (RHV) of the RPSG was anastomosed to the sidewall of the SFV graft. After explantation of native diseased liver was completed, the stenotic and thickened wall of the IVC was widely resected, and a large anastomotic orifice was created. Patch cavoplasty was performed with the RHV‒SFV graft patch. After portal reperfusion started, hepatic venous outflow was satisfactory, and there was no venous graft congestion. Both his postoperative course and his long-term course after discharge were uneventful. Conclusions In LDLT for BCS patients, ingenuity is required for the reconstruction of venous outflow. The SFV patch can be safely harvested from liver transplant recipients and is suitable for venous reconstruction. In addition, RPSG is an alternative type of liver graft for LDLT if a conventional right- or left-lobe graft cannot be used.

Background The right posterior segment (RPS) graft was introduced to overcome graft size discrepancy in living donor liver transplantation (LDLT). However, it was very rarely used in pediatric patients. Here we presented 4 pediatric LDLT cases receiving RPS graft between January 2015 and April 2020 in our center. A total of 1868 LDLT procedures were performed in this period. Methods Recipients included 1 boy and 3 girls with a median age of 45 months (range from 40 to 93 months). They were diagnosed with progressive familial intrahepatic cholestasis, propionic academia, ornithine transcarbamylase and biliary atresia, respectively. Four donors were all mothers with a median age of 32.5 years (31–38 years). Computer tomography angiography indicated posterior right branches branched off separately from main portal veins (type III variation). Three of these donor livers had 1 orifice of right hepatic veins (RHV). In the remaining 1 donor liver, the RHV showed 3 orifices and an outflow patch plastic was performed. Inferior right hepatic veins weren’t found in four donor grafts. The median graft weight was 397.5 g (352–461 g) and the median graft-to-recipient weight ratio was 2.38% (1.44–2.80%). Results Postoperative complications occurred in neither donors nor recipients. Within the median follow-up duration of 29 months (14–64 months), four children are all alive with normal liver function. Conclusion In summary, for older children weighed more than 15 kg with donors’ variation of type III portal veins, the use of RPS grafts could be a feasible and favorable option.

Summary Objective To discuss the utility and outcomes of bilateral myoneurectomy for treatment of abductor spasmodic dysphonia. Methods Bilateral myoneurectomy is a known treatment option for patients with adductor spasmodic dysphonia. Its use for treatment of abductor spasmodic dysphonia, however, has not been documented previously. In this case report, treatment and long-term outcomes of abductor spasmodic dysphonia with bilateral myoneurectomy are discussed. Results A 50-year-old male presented with abductor spasmodic dysphonia. His initial Voice Handicap Index-10 (VHI-10) score was 29, and he had breathy breaks during 60 series. He had no improvement in vocal quality after 6 botulinum toxin injections over 21 months. He underwent staged bilateral posterior cricoarytenoid partial myoneurectomy, with the left posterior cricoarytenoid myoneurectomy performed 33 months after presentation and right posterior cricoarytenoid myectomy 11 months later. Eight years postoperatively, his VHI-10 score was 12. During postoperative 60 series, the patient demonstrated few breathy breaks. Overall, the patient reports improved quality of life and satisfaction with his voice. Conclusion This is the first report of a long-term follow-up data for bilateral, endoscopic, partial posterior cricoarytenoid muscle myoneurectomy to treat refractory abductor spasmodic dysphonia. Long-term VHI-10 results suggest improvement of symptoms, despite mild difficulty with 60 series. While botulinum toxin therapy is the mainstay of management for abductor spasmodic dysphonia, surgical treatment is a potential alternative at least for refractory cases.

Laparoscopic cholecystectomy is a very frequent surgical procedure with a low complication rate. The reasons for such complications range from anatomical anomalies, obesity, poor exposure of anatomic structures, bleeding or lack of surgical experience. If complications arise, prompt recognition and correct management are essential. Early and correct treatment allows avoidance of serious complications, such as secondary biliary cirrhosis, hepatic failure, and ultimately death. In this paper is presented a case of a 40-years-old male patient, who sustained iatrogenic major bile duct, right hepatic artery and duodenum injury during routine laparoscopic cholecystectomy due to symptomatic gallstones.

The border between segments VI and VII of the right posterior sector of the liver is controversial owing to lack of anatomical landmarks. This study aimed to examine the segmentation of the right posterior sector. Using three-dimensional software, ramification type of the right posterior portal vein (RPPV) was analysed in 100 patients. A bow-shaped anatomy, in which the RPPV exhibits a downward convex bow shape with several ramifications, was found in 50 patients. A bifurcation anatomy, in which the RPPV bifurcates into the cranial and caudal branches, was observed in 45 patients. In the bow-shaped anatomy, setting the segmentation was difficult due to lack of definite landmarks; thus, the downward portal branches were determined as segment VI branches, while horizontal and upward branches were determined as segment VII branches. In the bow-shaped anatomy, the incidence of full exposure of a thick branch of the right hepatic vein on virtual transection surface was 60.0%, while in the bifurcation anatomy, it was only 11.1%. No relations were observed between RPPV anatomy and main PV/right hepatic vein anatomy. The volumes of segments VI and VII were equal in both the bow-shaped and bifurcation anatomy. The bow-shaped and bifurcation types are commonly observed in RPPV anatomy. In the bifurcation anatomy, the right posterior sector is divided into segments VI and VII. In the bow-shaped anatomy, setting the segmentation was difficult, thus it may be compelled to be arbitrarily determined.

Background: The one-stage approach for colorectal cancer (CRC) with synchronous liver metastases (SLM) has demonstrated advantages, when feasible, in terms of oncological radicality and reduction in sanitary costs. The simultaneous laparoscopic approach to both colon cancer and liver metastases joins the advantages of mini-invasiveness to the one-stage approach. Methods: During the period from February 2011 to July 2017, a single surgeon performed 17 laparoscopic colorectal operations with simultaneous liver resection for CRC with SLM. Colorectal procedures included 9 rectal resections, 6 left colectomies, and 2 right colectomies. Associated hepatic resections included 1 left hepatectomy, 1 right posterior sectionectomy, 2 segmentectomies, and 13 wedge resections. We analyzed retrospectively the patient's short-term outcome and operative and oncologic results. Results: There was no conversion to open surgery. Six patients (35%) had minor complications (Clavien-Dindo grade I-II), whereas only 2 patients (12%) had major complications (Clavien-Dindo grade III-IV) and no mortality occurred. The median time of discharge was 8.6 (range 5-36) days. We obtained 94% of R0 resection margin on the liver specimen and 100% of negative distal and circumferential margin in case of rectal resection. An average of 20 lymphnodes were retrieved in the colorectal specimen. Conclusions: Simultaneous mini-invasive colorectal and liver resection is a challenging but feasible procedure. The advantages of treating primary cancer and metastases in the same recovery justify the morbidity rate, especially because the most of the complications are minor and no cases of mortality occurred. Further experience is needed to better understand how to reduce the morbidity rate.

In our process of standardizing laparoscopic right-sided anatomical hepatectomy, we found several advantages of the caudate lobe-first approach. We herein describe our standardized procedure of laparoscopic right posterior sectionectomy (Lap-RPS) using this approach. Between January 2011 and January 2018, 31 patients underwent pure Lap-RPS in our hospital. The mean patient age was 68 years (range 47–85 years), and the number of male patients was more than that of female patients (64.5%). Of 31 patients, 20 had metastatic liver tumor, 7 had hepatocellular carcinoma, 3 had intrahepatic cholangiocellular carcinoma, and 1 had hemangioma. All 31 patients had Child–Pugh class A liver function. The surgical technique was recorded on video. Cumulative sum (CUSUM) analyses were applied to assess the learning curve. The mean operative time was 420 min (range 263–639 min), and the mean amount of blood loss was 304 g (range 10–900 g). No procedure was converted to open surgery. Postoperative bleeding, bile leakage, hepatic failure, and mortality did not occur. CUSUM analyses showed a decrease in the operative time and blood loss after using the caudate lobe-first approach. Our standardized procedure of Lap-RPS using the caudate lobe-first approach is not only feasible but also expected to provide an advantage for laparoscopic anatomical hepatectomy.

To report rare and clinically significant anatomic variations in the biliary drainage of right hepatic lobe. Unique variations in the extra- and intrahepatic biliary drainage of right hepatic lobe were observed in 6 cadaveric livers during dissection on 100 formalin-fixed en bloc cadaveric livers. There was presence of aberrant drainage of right segmental and sectorial ducts in four cases and of accessory right posterior sectorial duct in two cases. We encountered some extensively complicated biliary drainage of right hepatic lobe, unsuccessful recognition of which can lead to serious biliary complications during hepatobiliary surgeries and biliary interventions.

Language processing depends on an integrated circuit involving the left supratentorial language areas and the right posterior lateral cerebellar hemisphere (lobule VI, lobule VII, Crus I, and Crus II). Reorganization of the language system after lesions of the cerebral language areas includes also cerebellar relocation. This is the first study assessing functional language reorganization after lesions concerning primarily the cerebellum, using a fMRI paradigm of phonological covert word production task in six children operated for right cerebellar astrocytoma and in 15 typically developing children. We found right cerebellar and left frontal activations in healthy controls and high variability of reorganizational patterns in patients with early right cerebellar lesion. Also lesions not located in the areas typically involved in language tasks (Crus I and Crus II) can cause reorganization between the two hemispheres or hemispheric language reinforcement of the original lateralization. We discuss the role of several variables in determining the reorganizational pattern such as the site, extension, and timing of surgery. No variables revealed as predictors, suggesting that co-occurring influence of other biological and/or pathological factors are not yet demonstrated. Lesions in the postero-lateral cerebellum seem related to less efficient language performances, as an indicator of the system's functioning.

This study aimed at the effects of anodal transcranial direct current stimulation (tDCS) over the right posterior parietal cortex on the control of visual attention during walking in healthy adults. Twenty-four healthy participants received two conditions of tDCS (anodal and sham) in a double-blind, cross-over, and sham-controlled experimental study. The stimulus-response compatibility (SRC) effects were measured for assessing the control of visual attention at pre-intervention periods, immediate post-intervention periods, and 30 min after the intervention. Two-way repeated-measure analysis of variance was used to analyze the effects of time and stimulation condition in the entire field of view and each field of view (left and right). No significant changes in the SRC effects were observed in the entire field of view with respect to time (P = 0.14), tDCS condition (P = 0.42), and the combination of time and stimulation conditions (P = 0.66). Likewise, no significant changes in the SRC effects were observed in the left and right fields of view with respect to time (P = 0.08 and P = 0.78, respectively), tDCS condition (P = 0.17 and P = 0.98, respectively), and the combination of time and stimulation conditions (P = 0.37 and P = 0.85). Future studies using different stimulus conditions of tDCS (e.g., different electrode montage or timing of application) are required to evaluate the effects of tDCS on the control of visual attention during walking.

Langerhans cell histiocytosis is a rare condition ranging in manifestation from a focal boney lesion to multisystem involvement. Several treatment modalities have been proposed including curettage, low-dose radiotherapy, chemotherapy and intralesional injection of corticosteroids. These treatment options can be used as a single or combined approach. Prognosis depends on the extent of systemic involvement, and solitary lesions respond favorable to treatment. Here, the authors report a case of a 10-year-old male patient with Langerhans cell histiocytosis affecting his right posterior mandible that was successfully treated with intralesional injection of triamcinolone in multiple sessions. Complete recovery was confirmed clinically and radiographically in 18 months from the time of diagnosis.

Odontomas are considered a type of odontogenic hamartoma, and are generally reported not to exceed 3 cm in diameter. Some authors have referred to odontomas with a diameter exceeding 3 cm as giant odontomas. As hamartomas, giant odontomas generally show no signs or symptoms, but if they perforate the mucosa to become exposed in the oral cavity, oral and maxillofacial infections can result. Surgical removal and a histopathological examination may also be required to differentiate them from osteomas, cemento-osseous dysplasia, or mixed odontogenic tumors. This report presents the case of a 28-year-old woman with a giant odontoma in the right mandibular third molar area. Based on a review of the literature published since 2010, only 11 cases of "giant" or "large" odontomas have been reported, most of which were of the complex odontoma type. It was confirmed that they tend to occur in the right posterior mandible.

Objective To investigate the local initiation role of local exosomes of acupoints in acupuncture analgesic effect. Methods Thirty-two rats with adjuvant arthritis were randomly divided into model group (Group CFA), model + electroacupuncture group (Group EA), model + antagonist + electroacupuncture group (Group GW4869 + EA), and model + dimethyl sulfoxide + electroacupuncture group (Group DMSO + EA), with 8 rats in each group. The model rat s of adjuvant arthritis were prepared by intradermal injection of 0.1 mL of Freund's adjuvant complete into the metatarsal of the right posterior foot to induce inflammation. No intervention was given in Group CFA, while electroacupuncture was performed in the other three groups at “Zusānlĭ (足三里 ST 36, bilaterally)” and “Huantiao (环跳 GB 30, bilaterally)” of the rats with the following electroacupuncture parameters: dilatational wave with a frequency of 2/10 Hz, an intensity of 5/10/15 (0.76/1.53/2.3 mA), a duration of 30 min, and an intensity increasing every 10 min. In Group DMSO + EA, DMSO (with a concentration of 0.2%, 50µL/acupoint) was injected at bilateral “ST 36” of the model rats one hour before electroacupuncture, while GW4869 (with a concentration of 3 mg/mL, 50µL/acupoint) was injected at bilateral ST 36 of the model rats one hour before electroacupuncture in Group GW4869 + EA. The paw withdrawal latency (PWL) was used as the therapeutic effect index. Results The PWL of rats in each group at Hour 24 after modeling was significantly lower than that before modeling, indicating that the models were successfully established. After the electroacupuncture treatment, the PWL of rats showed an increasing trend in all groups. The PWL of Group GW4869 + EA (6.74 ± 1.09)s was lower than that of Group EA (7.72 ± 1.54)s on Day 1 after injection, but the difference was not statistically significant (P > 0.05). The PWL values of Group GW4869 + EA (7.72 ± 0.70)s, (7.87 ± 0.58)s were significantly lower than those of Group EA (9.96 ± 0.94)s, (9.66 ± 0.96)s (both P Conclusion It was preliminarily found that acupuncture analgesic effect was significantly reduced after local exosomes of acupoints were blocked, indicating that local exosomes of acupoints may be involved in the initiation process of acupuncture effect.

Primary adenoid cystic carcinoma in the trachea is a very rare tumor. A 40-year-old woman presented with persisting cough and wheezing over 2 months. A CT scan showed a mass in the tracheal wall. The bronchoscopic biopsy confirmed adenoid cystic carcinoma. 18F-FDG PET/CT was performed to evaluate the tracheal mass, which showed an FDG-avid mass in the right posterior tracheal wall.

In the present work, we applied anodal transcranial direct current stimulation (tDCS) over the posterior parietal cortex (PPC) and frontal eye field (FEF) of the right hemisphere in healthy subjects to modulate attentional orienting and disengagement in a gap-overlap task. Both stimulations led to bilateral improvements in saccadic reaction times (SRTs), with larger effects for gap trials. However, analyses showed that the gap effect was not affected by tDCS. Importantly, we observed significant effects of baseline performance that may mediate side- and task-specific effects of brain stimulation.

Knowledge of the anatomy of the portal system is essential for safe liver resection. We report a very rare anatomic anomaly of the portal system in a living liver donor. A 24-year-old female living liver donor was found to have anomalies of the portal system on preoperative contrast-enhanced computed tomography. The ventral branch of the right anterior segment arose from the transverse portion of the left portal vein. The gallbladder and round ligament were positioned normally. Intraoperative cholangiography for evaluation of biliary anatomy revealed very low confluence of the right and left hepatic ducts. All the bile ducts from the right lobe merged into the right hepatic duct. A right lobe graft was performed, including the ventral area of the right anterior segment. The portal branch of the ventral area of the right anterior segment could be transected extrahepatically. In the recipient operation, each of the right main portal branches, including the right posterior segment branch and the dorsal branch of the right anterior segment, and the ventral branch of the right anterior segment, were anastomosed to the right and left branches of the portal vein, respectively, of the recipient. The transected right hepatic duct of the graft was anastomosed with the recipient's common hepatic duct. Sixteen years after the liver transplant, the recipient continues to do well and has good portal flow.

Background Anatomic variation may increase the difficulty and risk of anatomic segmentectomy. The preoperative three-dimensional computed tomography bronchography and angiography (3D-CTBA) can provide a detailed model of the segmental structure, and contribute to precise and safe segmentectomy. Case presentation This is a case of anomalous bronchi and pulmonary vessels in the right upper posterior segment (RS2). Under the guidance of 3D-CTBA, anatomic RS2 segmentectomy was performed accurately and safely. The postoperative condition was uneventful. Conclusions This rare case highlights the importance of 3D-CTBA to guild accurate segmentectomy with anatomic variation.