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Background Combined resection of the right hepatic artery (RHA) is sometimes required to achieve complete resection of hilar cholangiocarcinoma. The present study aimed to evaluate the feasibility of combined resection and subsequent reconstruction by continuous suture of the RHA during left hepatectomy for cholangiocarcinoma. Materials and methods We retrospectively compared the outcomes after left hepatectomy with biliary reconstruction for cholangiocarcinoma between patients with and without RHA resection and reconstruction. Results Of the 25 patients who underwent left hepatectomy combined with biliary reconstruction, eight patients (32%) underwent combined resection and reconstruction of the RHA (AR group). The demographic characteristics were not different between the AR and non-AR groups. The amount of intraoperative bleeding was significantly greater in patients with AR (2350 mL vs. 900 mL, p = 0.017). The prevalence of early complications above grade III in Clavien–Dindo classification and late complications were not significantly different between the AR and non-AR groups. In the AR group, complications directly associated with AR, such as thrombosis or reanastomosis, were not observed. On Kaplan–Meier analysis, recurrence-free survival (p = 0.618) and overall survival (p = 0.803) were comparable between the two groups despite the advanced T stages in the AR group. Conclusions Combined resection and subsequent reconstruction of the RHA during left-sided hepatectomy is a feasible treatment alternative for cholangiocarcinoma.

Background This study evaluates the safety and feasibility of combined resection for patients with synchronous pulmonary and esophageal cancer. Methods Patients undergoing esophagectomy between 1997 and 2019 were identified from prospectively collected databases at three tertiary referral centers, and those with combined anatomic lung resection at the same setting were identified. This cohort was then matched in a 1:3 ratio to esophagectomy alone cases, based on age, sex, pathologic stage, neoadjuvant therapy, and surgical procedure. Demographic data, peri-operative data, post-operative complications were compared. Statistical analysis included unpaired t-test, Fisher’s exact or chi-squared test and Gehan-Breslow analysis. Results Of 4729 esophagectomies, combined anatomic lung resection was performed in 18 patients with discrete pulmonary lesions. Matching yielded 49 patients who underwent esophagectomy only and was statistically similar compared to patients undergoing combined resections. Ivor Lewis esophagectomy and lobectomy were the most frequent procedures. Combined resections did not have a higher overall complication rate than esophagectomy alone, rather these patients had fewer overall complications (56% vs 84%; p=0.02). Specifically, there was not difference in anastomotic leak (17% vs. 18%) or pulmonary complications (39% vs. 33%) between combined resection and esophagectomy alone. No post-operative mortality was identified, and median overall survival was 4.1 years versus 6.5 years (p=0.10). Conclusions Patients with synchronous localized lung and esophageal cancer, although rare, should not be biased towards non-surgical therapy, as the morbidity associated with combined esophagectomy and anatomic lung resection does not differ significantly from esophagectomy alone in this highly selected group of patients.

AIM To validate the utility of hepatic resection combined with complementary radiofrequency ablation (RFA) compared with resection alone for patients with multiple hepatocellular carcinoma (HCC), and to compare these results with those of a previous report. MATERIALS AND METHODS A total of 78 HCC patients with multiple (≤5) tumours who were initially treated with hepatic resection only (Resection group) or with combined hepatic resection and RFA (Combination group) were included. Overall and disease-free survival were analysed. RESULTS There were 21 women and 57 men with a median age of 72.5 (64.3–76.8) years. Fifty-three patients were treated with resection alone and 25 received combination therapy. The 3-, 5-, and 7-year cumulative overall survival rates were 81.2%, 68.2%, and 57.1%, respectively, in the Resection group, and 81.3%, 59.6%, and 42.4%%, respectively, in the Combination group (hazard ratio [HR], 1.462; 95% confidence interval [CI], 0.682–3.136; p=0.329). The 1-, 3-, and 5-year cumulative disease-free survival rates were 61.4%, 45.7%, and 39.8%, respectively, in the Resection group, and 53.1%, 18.6%, and 0%, respectively, in the Combination group (HR, 2.080; 95% CI, 1.157–3.737; p=0.014). The overall survival rate was not significantly different between the Resection and Combination groups in patients within the up-to-seven HCC criteria (n=56; HR, 2.101; 95% CI, 0.805–5.486; p=0.130) or those beyond these criteria (n=22; HR, 0.804; 95% CI, 0.197–3.286; p=0.761). CONCLUSIONS The combination of hepatic resection and RFA therapy may be an effective strategy for HCC patients with multiple tumours.

Purpose: To compare the efficiency of bilateral combined resection-recession surgery of the medial rectus muscle versus using a modified Fadenoperation for surgical management of esotropias that totally resolve under general anesthesia, which we called “purely tonic” esotropias. Methods: We included 65 unselected consecutive cases of patients with purely tonic esotropias who underwent surgery between October 2017 and 2018. Patients were divided into group I, who underwent a combined resection and recession of medial recti muscles, and group II, who underwent a bilateral medial rectus Fadenoperation using posterior strapping. A satisfactory outcome was defined as deviation ⩽10 prism diopters (PD), at near and distance fixation, between 3 and 6 months postoperatively. Results: Mean initial deviation was in group I, 19.6 PD and 32.0 PD, in group II, 23.6 PD and 33.5 PD, at distance and near fixation respectively. Postoperatively, in group I, 31 patients (91.2%) showed satisfactory alignment at near and distance fixation. Post-operatively, in group II, 25 patients (80.6%) showed satisfactory alignment at near and distance fixation. Conclusion: Our results suggest both techniques are good options to treat purely tonic esotropias.

Remote-access total endoscopic thyroidectomy (TET) is a recently established approach that can avoid producing scars in the neck. There are no clear surgical indications for TET for benign nodules or for malignant tumors at present. We report a successful TET in a 50-year-old Japanese woman with follicular lymphoma of the thyroid gland after an open neck biopsy. She had been referred to us with a neck tumor noted 2 months earlier. Because of adhesion, we performed a combined resection of the thyroid and partial right sternohyoid muscle. To the best of our knowledge, there is no other report of a TET performed after open neck surgery. Our patient's case demonstrates that (a) the cosmetic outcome of TET is clearly superior to that of conventional open neck surgery, and (b) a TET can be suitable even for reoperation if carefully selected.

Introduction: Widespread differences in patient demographics and disease burden between hospitals for resection of colorectal liver metastases (CRLM) have been described. In the Netherlands, networks consisting of at least one tertiary referral centre and several regional hospitals have been established to optimize treatment and outcomes. The aim of this study was to assess variation in case-mix, and outcomes between these networks.Methods: This was a population-based study including all patients who underwent CRLM resection in the Netherlands between 2014 and 2019. Variation in case-mix and outcomes between seven networks covering the whole country was evaluated. Differences in case-mix, expected 30-day major morbidity (Clavien-Dindo >= 3a) and 30-day mortality between networks were assessed.Results: In total 5383 patients were included. Thirty-day major morbidity was 5.7% and 30-day mortality was 1.5%. Significant differences between networks were observed for Charlson Comorbidity Index, ASA 3+, previous liver resection, liver disease, preoperative MRI, preoperative chemotherapy, >= 3 CRLM, diameter of largest CRLM >= 55 mm, major resection, combined resection and ablation, rectal primary tumour, bilobar and extrahepatic disease. Uncorrected 30-day major morbidity ranged between 3.3% and 13.1% for hospitals, 30-day mortality ranged between 0.0% and 4.5%. Uncorrected 30-day major morbidity ranged between 4.4% and 6.0% for networks, 30-day mortality ranged between 0.0% and 2.5%. No negative outliers were observed after case-mix correction.Conclusion: Variation in case-mix and outcomes are considerably smaller on a network level as compared to a hospital level. Therefore, auditing is more meaningful at a network level and collaboration of hospitals within networks should be pursued. (C) 2021 Published by Elsevier Ltd.

Introduction: Duodenal adenocarcinoma is a rare malignancy; recently, it has been found to be accompanied by operative indications., Methods: Nine consecutive rare cases were diagnosed with duodenal carcinoma (DC), in which clinicopathological characteristics were retrospectively examined. Age was ranged over middle-aged males and females. No clinical onset with severe symptoms was observed, and the specific treatment for accompanied diseases or habits was not found., Outcomes: One case of two T1 stage DCs that underwent pancreas-sparing duodenectomy. Stage II DC was diagnosed in three cases, and stage III DC was diagnosed in four cases. Pancreaticoduodenectomy (PD) mainly occurred in seven patients, and duodenectomy was limited in two patients. All operations were safely performed, and the postoperative course showed no severe morbidity. Histological findings showed R0 resection in eight cases and R1 at the retroperitoneal dissecting part in one case. Five patients with advanced-stage DC underwent adjuvant chemotherapy; however, four patients showed tumor recurrence within 12months. With additional strong chemotherapy, eight patients survived up to 84months, and one died of liver metastasis at 43months after surgery. Three representative cases of mucosal invasion with widespread pancreas-sparing duodenectomy and advanced-stage DC cases undergoing duodenectomy or PD are shown., Conclusion: In the field of upper digestive tract surgery, duodenal adenocarcinoma and various applications of surgery or adjuvant chemotherapy for long-term survival are important.

Background Although complete surgical resection of thymic carcinoma is a prognostic factor, it is not always an option for advanced tumors because of locoregional invasion. Extended surgery combined with a major blood vessel procedure remains controversial because of the increased risk of mortality. Case presentation Chest computed tomography (CT) uncovered an abnormal shadow in the mediastinum of a 74-year-old man. An irregularly shaped tumor obstructed the left innominate vein, and invasion of the aortic arch was suspected. A CT-guided percutaneous needle biopsy revealed squamous cell carcinoma of the thymus, which was considered unresectable. The patient underwent chemotherapy elsewhere, then was referred to us for surgical resection. We combined extended surgery with total aortic arch replacement under a cardiopulmonary bypass. Complete resection was achieved, and the patient remains alive without recurrence at 3 years after surgery Conclusion Resection including aortic arch replacement might be an option that can achieve complete resection of local advanced thymic carcinoma.

We analyzed the significance of portal vein (PV) patency ratio (minimum diameter/maximum diameter) during preoperative chemoradiotherapy (CRT) on the outcomes of patients with pancreatic-ductal adenocarcinoma (PDAC).The 261 PDAC patients had been prospectively registered to our CRT protocol (Gemcitabine or S1+Gemcitabine) from 2005 to 2015. Among them, the subjects were the 84 PDAC- patients with preoperative PV contact who underwent pancreatectomy with PV resection.The 3- and 5-year disease-specific survival (DSS) rates of all 84 patients were 44% and 39%, respectively. Pathological PV invasion (pPV) was seen in 22, and PV patency ratio after CRT (cut-off:0.62) was most relevant factor to predict pPV (sensitivity:54.8%, specificity:91.9%, accuracy:81.5%). Multivariate analysis revealed that PV patency ratio after CRT and improvement of PV patency ratio were selected as independent prognostic indicators. The 3- and 5-year DSS in 39 patients with PV patency ratio after CRT0.6 were significantly higher than those in 45 patients0.6: 65% and 60% vs. 24% and 20% (p = 0.0001). The patients with PV patency ratio0.6, were significantly associated with the lower incidence of pPV, higher response for CRT, and better R0 resection rate. Even when severe PV strictures were seen before CRT, DSS of the patients whose PV patency ratio had recovered after CRT was excellent compared with those without improvement.The PV patency ratio and its improvement are new prognostic indicators for PDAC treated with preoperative CRT. Even when PV was severely constricted, patients could obtain favorable outcomes, if its patency had recovered after CRT.

Carbon ion radiotherapy (CIRT) shows higher local control rates and minimal damage to normal lung parenchyma compared with conventional radiotherapy; however, some patients experience local recurrence. The efficacy and safety of salvage surgery after CIRT for non-small-cell lung cancer are unclear. We reviewed clinical, surgical, pathological and prognostic data of 6 patients who underwent salvage surgery after CIRT between 2010 and 2015. All patients were men with a smoking history, and their median age was 67 years. The time from CIRT to surgery was 18 (range 12-24) months. All patients underwent at least lobectomy with mediastinal node dissection. Viable tumour cells were confirmed pathologically in all cases. Five patients required combined resection or extra procedure because of strong adhesions and the possibility of tumour extension; however, none of the patients had a tumour invasion to the adjacent organ. None of the patients had severe complications, perioperative death and local recurrence, and 3 patients are alive without recurrence (range 28-84 months). Salvage surgery appears to be safe and effective. Even though the tumours did not invade the adjacent organs, combined resection was required because of severe adhesion.

Extended cholecystectomy is the standard surgical procedure for gall bladder cancer (GBC), but very few patients with a preoperative diagnosis of GBC are suitable for it. Many patients with advanced GBC need more major resections. GBC patients with jaundice need CBD excision along with extended cholecystectomy and often require a major hepatectomy in the form of extended right hepatectomy (ERH). These patients require extensive invasive preoperative preparation in the form of preoperative biliary drainage and portal vein embolization. Morbidity of major hepatectomy for GBC is high and mortality is significant. Hepato-pancreatoduodenectomy (HPD) for GBC is debatable and its role is being questioned. Combined resection of adjacent organs (CRAO), e.g., colon and duodenum, is very frequently required to achieve R0 resection. Vascular, hepatic artery and portal vein, resection is not recommended for GBC.

We aimed to investigate the impact of the site of the primary on postoperative and oncological outcomes in patients undergone simultaneous approach for colon (CC) and rectal cancer (RC) with synchronous liver metastases (SCRLM).Of the 220 patients with SCRLM operated on between Mar 2006 and Dec 2017, 169 patients (76.8%) were treated by a simultaneous approach and were included in the study. Two groups were considered according to the location of primary tumor RC-Group (n = 47) and CC-group (n = 122).Multiple liver metastases were observed in 70.2% in RC-Group and 77.0% in CC-Group (p = 0.233), whilst median Tumor Burden Score (TBS) was 4.7 in RC-Group and 5.4 CC-Group (p = 0.276). Severe morbidity (p = 0.315) and mortality at 90 days (p = 0.520) were comparable between RC-Group and CC-Group. The 5-year overall survival (OS) rate was similar comparing RC-Group and CC-Group (48.2% vs. 45.3%; p = 0.709), but it was significantly different when considering left-CC, right-CC and RC separately (54.5% vs. 35.2% vs. 48.2%; p = 0.041). Primary tumor location (right-CC, p = 0.001; RC, p = 0.002), microscopic residual (R1) disease at the primary (p 0.001), TBS ≥6 (p = 0.012), bilobar metastases (p = 0.004), and chemotherapy strategy (preoperative ChT, p = 0.253; postoperative ChT, p = 0.012; and perioperative ChT, p 0.001) resulted to be independent prognostic factors at multivariable analysis.In patients with SCRLM, simultaneous resection of the primary tumor and liver metastases seems feasible and safe and allows satisfactory oncological outcomes both in CC and RC. Right-CC shows a worse prognosis when compared to left-CC and RC.

Complete resection of intra-abdominal recurrence of colorectal cancer is difficult because of complex anatomical changes following primary surgery and indefinite cancer demarcation. Here, we demonstrate the effect of surgery using three-dimensional (3D) printed model and 3D virtual images on the achievement of complete resection. We enrolled 11 cases who had undergone combined resection of adjacent organs for colorectal cancer recurrence, including localized peritoneal dissemination of colon cancer and local recurrence of rectal cancer, between January 2016 and July 2018. We created 3D virtual images of nine cases and 3D models of two cases and used them for intraoperative navigation. Simulation and navigation using 3D technologies potentially helped the surgeons to comprehend the complex anatomy and perform challenging surgeries. Macroscopic negative margins were achieved in all cases, including R0 resection in 8 of the 11 cases. 3D navigation tools are potentially useful to complete the resection of intra-abdominal recurrence of colorectal cancer.

Background: Only few surgeons have tried to perform laparoscopic combined resection for T4b gastric cancer. The purpose of this study was to investigate the feasibility of laparoscopic combined resection through a comparison of the clinical outcomes between cT4a and cT4b cases. Methods: We reviewed the medical charts of patients who underwent laparoscopic gastrectomy for clinically T4 gastric cancer from May 2014 and July 2018. During this period, 62 patients with serosa-positive gastric cancer underwent laparoscopic curative surgery. The patients were divided into the following groups: patients who underwent gastrectomy and combined resection for the invaded organs (combined resection group) and those who did not undergo combined organ surgery (gastrectomy only group). Clinical outcomes were compared between the gastrectomy only and combined resection groups. Results: Of 62 patients included in this study, 43 and 19 patients were included in the gastrectomy only and combined resection groups, respectively. The operation time was significantly longer in the combined resection group (364.6 ± 102.5 vs. 247.7 ± 66.1 min; p < 0.001). The incidence of grade ≥ III complications was comparable between the groups (26.3% vs. 11.6%; p = 0.147). The time from the first operation to the initiation of adjuvant chemotherapy showed no statistically significant difference between the groups (48.1 ± 45.4 days vs. 31.6 ± 9.2; p = 0.134). Conclusions: Focusing on the high quality of image and new devices of laparoscopic surgery, it is necessary to re-evaluate the oncologic outcomes of combined resection for T4b gastric cancer.

Introduction The purpose of this study was to investigate the protective effect of hydrogen-rich saline (HRS) against liver ischaemia-reperfusion combined resection injury. Material and Methods Eighteen miniature pigs were randomly divided into three groups: a sham operated group (sham group, laparoscopic liver ischaemia-reperfusion combined resection injury group (IRI group), and a hydrogen-rich saline intervention group (IRI + HRS group). Samples of hepatic tissue and serum were collected at the time of reperfusion and then 3 h, 1 d, and 3 d post reperfusion. Liver function, oxidative stress, autophagy-related mRNA genes, and protein expression were evaluated. Changes in cell and tissue ultrastructure were examined by transmission electron microscopy. Results Compared with the sham group, the level of autophagy of hepatocytes increased in the IRI and IRI + HRS groups, corresponding to high oxidative stress and severe liver function injury. Liver function, antioxidant content, autophagy levels, and liver injury were improved after intervention with HRS in the IRI + HRS group compared with the IRI group. Conclusion Intervention with hydrogen-rich saline could exert a protective effect against liver ischaemia-reperfusion combined resection injury through the reduction of oxidative stress and hepatocyte autophagy.

It is presented clinical observation of the patient living over 8 years after extended right-sided hemihepatectomy with resection and replacement of the inferior vena cava for locally advanced hepatocellular carcinoma. The authors emphasize the need for only aggressive surgical approach to achieve satisfactory long-term outcomes in these patients. The possibilities of transplantation techniques in particular complete vascular isolation of the liver and temporary veno- venous bypass are discussed.

Highlights • In case of cholangiocarcinoma invading hilar vessels, adequate simulations and expert skills are required to achieve R0 resection., Introduction The present case report demonstrated the successfully radical operation (R0) for the highly advanced cholangiocarcinoma involving hilar hepatic arteries and portal vein, The careful preoperative diagnosis to define the adequate resection area and the expert operation was achieved without postoperative severe complications. Presentation of case A 55-year-old male was admitted to our hospital with obstructive jaundice, and the perihilar cholangiocarcinoma (PC) was found. At the time of finding PC, enhanced computed tomography showed the widely extension and involved the surrounding right hepatic artery (RHA) and bilateral portal veins (PV). According to extension of PC, left trisectionectomy combined resection of RHA and PV trunk was scheduled. By supporting plastic surgeon’s procedure, the scheduled R0 operation could be achieved and the patient was discharged without any severe complication but delayed intrahepatic abscess formation. After abscess drainage, he could immediately recovered and tumor relapse was not observed for a couple of months. By carefully preoperative examination, a complicated operation was successfully completed. Discussion The major hepatectomy with arterio-portal resections and anastomosis for advanced has been challenged at the high-volume center and the improvement of survival seemed to be obtained and, however, operative risk is still remained. This operation could be achieved by the expert surgeons under precise planning or management. Conclusion The role of HBP surgeons is to challenge aggressive surgery even for patients with highly advanced local extension of PC.

PURPOSE The significance of hospital volume remains inconsistent and controversial. In particular, few studies have examined whether hospital volume is associated with the outcome of gastrectomy for gastric cancer in East Asia. This study examined the effect of hospital volume on the short-term surgical and long-term oncological outcomes of patients undergoing curative gastrectomy for gastric cancer. MATERIALS AND METHODS Between 2009 and 2011, 1,561 patients underwent curative gastrectomy for gastric cancer at Seoul St. Mary's Hospital (n=1,322) and Bucheon St. Mary's Hospital (n=239). We defined Seoul St. Mary's Hospital as a high-volume center and Bucheon St. Mary's Hospital as a low-volume center. RESULTS The extent of resection, rate of combined resection, tumor stage, operating time, and hospital stay did not differ significantly between the 2 hospitals. In addition, the hospital volume was not significantly associated with the 30-day morbidity and mortality. When the overall and disease-free survival rates of the patients were stratified according to stage, hospital volume was not significantly associated with prognosis at any stage. CONCLUSIONS Hospital volume might not be a decisive factor with respect to the surgical and oncological outcomes of patients if well-trained surgeons perform gastrectomy for gastric cancer.

Manar A Ghali Ophthalmology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt Purpose: To compare and evaluate the efficacy of two different surgical techniques for the treatment of near-distance disparity esotropia; combined resection–recession and recession–retroequatorial myopexy of medial rectus muscles. Patients and methods: This prospective study included 28 patients diagnosed with convergence excess esotropia who had worn their full cycloplegic refraction and/or bifocal glasses for at least 6 months and still had near-distance disparity esotropia. The patients were divided into 2 groups; Group I underwent combined bimedial rectus muscles resection 2.5mm from the insertion end with recession based on near-angle esotropia according to current surgical tables with 1 mm add of recession for each muscle, while Group II underwent bimedial recession based on far angle combined with retroequatorial myopexy at 13–14mm from insertion. A satisfactory result was defined as orthophoria or esotropia 10 ∆. Conclusion: The technique of combined resection–recession is safe, easy and more effective in the treatment of near-distance disparity esotropia regardless of the level of accommodative convergence/accommodation ratio, with stability of results though longer follow-up period is still needed. Keywords: near-distance disparity, esotropia, Ac/A ratio, retroequatorial myopexy, slanted recession

Key Clinical Message We encountered a patient with a large retroperitoneal solitary fibrous tumor, in whom we could preserve approximately 150 cm of the ileum even after pancreaticoduodenectomy combined with resection of the superior mesenteric artery, thus preventing short bowel syndrome.

Herein, we describe the operative procedure for combined resection of re-recurrent lateral lymph nodes and the external iliac vein. There is no consensus on the clinical implications of resection of locally re-recurrent colorectal tumors, as the operative procedure is extremely difficult. We present the case of a 52-year-old woman who underwent abdominoperineal resection. About one year later, we excised a recurrent lymph node in the left lateral obturator area through an extraperitoneal approach. About 18 months later, lymph node re-recurrence in the left external iliac area was observed. Re-recurrent lymph nodes directly invade the left external iliac vein. We removed the re-recurrent lymph node with combined, radical segmental resection of the left external iliac vein, left obturator artery and vein, and left obturator nerve. J. Med. Invest. 65:136-138, February, 2018.

Introduction:The methods of liver parenchymal transection vary across institutions. In this study, we used a radiofrequency (RF) sealer (Aquamantys) as a hemostatic device during laparoscopic liver transection; we also evaluated the usefulness of RF sealers., Methods:From April 2016 to May 2019, 113 consecutive laparoscopic hepatectomy patients, excluding patients with combined resection of other organs, were examined. Patient characteristics, operative factors, and postoperative complications were compared between the Cavitron ultrasonic surgical aspirator (CUSA) + soft coagulation system (VIO) group; (n = 32) and the CUSA + Aquamantys group; (n = 81). The former underwent liver transection by CUSA and VIO from April 2016 to March 2017, while the latter underwent liver transection using CUSA and Aquamantys from April 2017 to May 2019., Results:The median difficulty score was significantly higher in the CUSA + VIO group (5.5 points vs 5.0 points; P = .04). Blood loss per unit area and the liver parenchymal transection speed were not significantly different between the groups. After propensity score matching, blood loss per unit area was similar between the groups, but the parenchymal transection speed of the CUSA + Aquamantys group was significantly higher (0.92 cm2 /min vs 0.64 cm2 /min; P = .017). Postoperative complications were similar between the groups., Conclusion:In laparoscopic hepatectomy, hemostasis of the transection plane with an RF sealer did not reduce blood loss during parenchymal transection. However, the liver parenchymal transection speed was increased.

When performing PDS, it is desirable to achieve complete surgery. Accordingly, cases in which complete tumor resection is considered possible are selected. However, it is extremely difficult to accurately determine preoperatively whether complete resection is possible in advanced cases. As combined resection of organs other than the internal genitalia is often required to achieve complete excision for cases of advanced ovarian cancer, this means that large-scale surgical intervention is necessary. When performing such procedures, it is vital to avoid having to prematurely stop the resection despite it being incomplete. Therefore, it is optimal to be able to accurately determine whether complete resection can be performed on the basis of preoperative tests or minimally invasive procedures. The details of surgery depend on the comprehensive ability of that specific hospital. It is vital that each facility investigates what surgical procedure can be performed safely and without causing any disadvantage to the patient beforehand.

Background: The liver is the most common site of metastases for colorectal cancer, and combined resection with systemic chemotherapy is the most effective strategy for survival. The aim of this article is to provide a comprehensive summary on four hot topics related to chemotherapy and surgery for colorectal liver metastases (CLM), namely: (1) chemotherapy-related liver injuries: prediction and impact, (2) surgery for initially unresectable CLM, (3) the emerging role of RAS mutations, and (4) the role of hepatic arterial infusion of chemotherapy (HAIC). Summary and Key Messages: (1) The use of chemotherapy before liver resection for CLM leads to drug-specific hepatic toxicity, which negatively impacts posthepatectomy outcomes. (2) Curative liver resection of initially unresectable CLM following conversion chemotherapy should be attempted whenever possible, provided that a safe future liver remnant volume is achieved. (3) For CLM, RAS mutation status is needed to guide the use of targeted chemotherapy with anti-epithelial growth factor receptor (EGFR) agents, and is a major prognostic factor that may contribute to optimize surgical strategy. (4) HAIC agents increase the rate of objective response and the rate of complete pathological response.

Highlights • The aberrant right hepatic artery is often arising from superior mesenteric artery. • Combined resection of the aberrant right hepatic artery is necessary in pancreaticoduodenectomy for pancreatic head cancer to achieve R0 resection. • Arterial anastomosis of combined resection is not always necessary because of existence of communicating artery from the middle and left hepatic artery via hepatic hilar plate. • R0 resection without tumor exposure at the dissected plane improves prognosis of pancreatic cancer patients., Introduction This case report is intended to inform pancreas surgeons of our experience in operative management of aberrant pancreatic artery. Presentation of case A 63-year-old woman was admitted to our institute’s Department of Surgery with obstructive jaundice, and the pancreas head tumor was found. To improve liver dysfunction, an endoscopic retrograde nasogastric biliary drainage tube was placed in the bile duct. Endoscopic fine-needle aspiration showed a pancreas head carcinoma invading the common bile duct, the aberrant right hepatic artery arising from the superior mesenteric artery, and the portal vein. Enhanced computed tomography showed the communicating artery between the right and left hepatic artery via the hepatic hilar plate. By way of imaging preoperative examination, a pancreaticoduodenectomy combined resection of the aberrant right hepatic artery and portal vein was conducted without arterial anastomosis. Hepatic arterial flow was confirmed by intraoperative Doppler ultrasonography, and R0 resection without tumor exposure at the dissected plane was achieved. The patient’s postoperative course was uneventful. Discussion In this case report, perioperative detail examination by imaging diagnosis with respect to hepatic arterial communication to achieve curative resection in a pancreas head cancer was necessary. Non-anastomosis of hepatic artery was achieved, and the necessity of R0 resection was stressed by such management. Conclusion By the preoperative and intraoperative imaging managements conducted, combined resection of the aberrant right hepatic artery without anastomosis was achieved by pancreaticoduodenectomy for pancreas head cancer. However, improvements in imaging diagnosis and careful management of R0 resection are important.

341 Background: Resection is the best treatment for both esophagus and lung cancer, however, concerns that a combined resection of synchronous lung/esophagus tumors might be associated with higher morbidity may preclude surgical therapy. We sought to review a multi-institutional experience on combined esophagus/lung cancer resections. Methods: Patients undergoing esophagectomy and those with concurrent anatomic resection for bronchogenic carcinoma between 1997-2018 at three high-volume North American centers were identified from prospectively collected databases. Combined resection cases (E+L) were matched in a 1:3 ratio to patients who underwent esophagectomy alone (E), based on age, sex, stage, neoadjuvant therapy, procedure (2/3hole), and approach (MIE/open). Patient demographics, tumour characteristics, and post-operative outcomes were compared. Statistical analysis was performed using unpaired t-test or Wilcoxon sum-rank test for continuous variables and Fisher’s exact test for categorical data. Statistical significance was defined as p < 0.05. Results: Of over 2500 patients undergoing esophagectomy, synchronous anatomic lung resection was performed in 20; 4 were excluded due to incomplete data (n = 16). Matching yielded 48 patients and 4 duplicates were removed (n = 44); there were no significant differences in patient demographics, neoadjuvant therapy, clinical stage, or procedure. Anatomic resection consisted of lobectomy (16/20), segmentectomy (3/20) and pneumonectomy (1/20), combined with 2-hole (14/20), 3-hole (4/20), or left thoraco-abdominal (2/20) esophagectomy. The proportion of patients with any complication in E+L was 50%, and 66% in E (p = 0.42). Pulmonary complications were 19% and 27% in the respective groups (p = 0.74). Mortality did not differ (E+L = 0/16:E = 1/44)NS. The median length of stay for both groups was similar (E+L = 10.5 days(IQR 5.7): E = 10.0 days (IQR 8.7))NS. Conclusions: Patients with synchronous localized lung and esophageal cancer, although rare, should not be biased towards non-surgery therapy, as the morbidity associated with combined esophagectomy and anatomic lung resection does not differ significantly from esophagectomy alone.

This study determines the oncologic outcome of the combined resection and ablation strategy for colorectal liver metastases. Between January 1994 and December 2015, 373 patients underwent surgery for colorectal liver metastases. There were 284 patients who underwent hepatic resection only (Group 1) and 83 hepatic resection plus ablation (Group 2). Group 2 patients had a higher incidence of multiple metastases (100% in Group 2 vs 28.2% in Group 1; P < 0.001) and bilobar involvement (76.5% in Group 2 vs 12.9% in Group 1; P < 0.001) than Group 1 cases. Perioperative mortality was nil in either group, with a higher postoperative complication rate among Group 1 versus Group 2 cases (18 vs 0, respectively). The median follow-up was 90 months (range, 1–180), with a five-year overall survival for Group 1 and Group 2 of 51 per cent and 80 per cent, respectively (P = 0.193). Mean disease-free survival for patients with R0 resection was 55 per cent, 40 per cent, and 37 per cent at one, two, and three years, respectively, and remained steadily higher (at 50%) in those patients treated with resection combined with ablation up to five years (P = 0.069). The only intraoperative ablation failure was for a large lesion (≥5 cm). Our data support the use of intraoperative ablation when complete hepatic resection cannot be achieved.

Aim: to study particular features of resumption of working capacity after resection in patients with destructive tuberculosis of lungs revealed for the first time. Methods: 248 patients: men - 195, women - 53, aged 18-67 years were observed during 5 months -17 years after operation. Complex rehabilitation measures (chemical therapy 5-10 months, health resorts). Results: Resumption of working capacity is 96,37% (239 out of 248). 119 - in 5-12 months and 40 - in 1-2 years. 224 of 239 the same job, easier job -7, housekeeping - 5, and 3 stopped working of health reason. The fastest (5 months) resumption was after organ-saving operation and economical resection (112 of 182) and then (7 months) after lobectomy and combined resection (14 of 47). Best results (10-12 months) in operated of tuberculoma 128 of 159, then (1-2 years) fibrocavernous tuberculosis 28 of 70. Limited tuberculosis process - 175 of 192 in 5 months, disseminated - 14 of 47 in 10 months. Conclusions: Resumption of work capacity after operation in patients with destructive tuberculosis of lungs revealed for the first time directly depends on the volume of the operation, clinic form of tuberculosis, dissemination of the process, timely diagnosis and type of work.

While colorectal and hepatic resections are commonly performed through a laparoscopic approach, the safety and feasibility of total laparoscopic synchronous resections (LSR) of colorectal liver metastasis (CRLM) have not been established. In this systematic review, short- and long-term outcomes were comparable for patients undergoing LSR and open synchronous resection. LSR was safe and feasible for patients with synchronous CRLM and should be considered in well-selected patients.

A 64-year-old man underwent right upper lobectomy combined resection with third-fifth rib for lung cancer and reconstruction of chest wall using Dual Mesh. Six days after surgery, he experienced acute severe pain in the right shoulder. The purulent drainage through the drainage tube was also found. Chest CT showed that the inferior angle of the scapula protruded into the right intrathoracic cavity. We performed a removal of Mesh. Although we did not want to use synthetic materials because of infection, we performed titanium plate fifth rib fixation to avoid the recurrent dislocation of the scapula. After the redo surgery, continuous lavages with physiologic saline of the thoracic cavity was also performed. Patient is now doing well without recurrences of cancer, infection and scapular dislocation, 14 months after the redo surgery.

Background Surgeons sometimes must plan pancreatoduodenectomy (PD) for patients with a variant common hepatic artery (CHA) branching from the superior mesenteric artery (SMA) penetrating the pancreatic parenchyma, known as a transpancreatic CHA (tp-CHA). Case presentation A 67-year-old man was admitted to our hospital because of liver dysfunction. A duodenal tumor was identified by gastrointestinal endoscopy, and a biopsy revealed a neuroendocrine tumor. Computed tomography showed multiple metastases in the left three sections of the liver. As an anatomical variant, the CHA branched from the SMA and passed through the parenchyma of the pancreatic head, and all hepatic arteries branched from the CHA. Furthermore, the arcade between the left and right gastric artery (RGA) was detected, and the RGA branched from the root of the left hepatic artery. PD and left trisectionectomy of the liver were performed. The tp-CHA was resected with the pancreatic head, and the gastric arterial arcade was preserved to maintain the right posterior hepatic arterial flow. Postoperatively, there were no signs of hepatic ischemia. Conclusions When planning PD, including hepatopancreatoduodenectomy, for patients with a tp-CHA, surgeons should simulate various situations for maintaining the hepatic arterial flow. The preservation of the gastric arterial arcade is an option for maintaining the hepatic arterial flow to avoid arterial reconstruction. Electronic supplementary material The online version of this article (10.1186/s40792-018-0474-8) contains supplementary material, which is available to authorized users.

We present a case of asymptomatic residual coarctation following combined resection and isthmusplasty with implantation of the left internal thoracic artery distal to the repair 30 years ago.

The aim of this study was to examine the feasibility of performing combined laparoscopic resection in patients with synchronous gastric and colorectal cancer.Thirty-six consecutive patients with synchronous gastric and colorectal cancer who underwent simultaneous combined resection were enrolled in this retrospective study.Six patients underwent laparoscopic combined resection (lap group), whereas the other 30 patients underwent conventional open combined surgery (open group). Although the operative time was longer in the lap group than in the open group, there were no differences in the amount of intraoperative bleeding. Although there were no differences in the rates of postoperative complications between the 2 groups, the postoperative hospital stay was significantly shorter in the lap group. During a mean follow-up of 35 months, all 6 patients who underwent laparoscopic combined resection survived without any signs of recurrence.Simultaneous laparoscopic resection is a feasible procedure in patients with synchronous gastric and colorectal cancer.

Nowadays, sublobar anatomic resections are gaining momentum as a valid alternative for early stage lung cancer. Despite being technically demanding, anatomic segmentectomies can be performed by uniportal video-assisted thoracic surgery (VATS) approach to combine the benefits of minimally invasiveness with the maximum lung sparing. This procedure can be even more complex if a combined resection of multiple segments from different lobes has to be done. Here we report five cases of combined and unusual segmentectomies done by the same experienced surgeon in high volume institutions to show uniportal VATS is a feasible approach for these complex resections and to share an excellent educational resource.

To determine if a select subgroup of patients with combined liver and peritoneal colorectal metastases would derive oncologic benefit from surgical resection as a component of multimodality treatment.We retrospectively compared 32 patients with combined colorectal peritoneal and liver metastases (CRLM) and 173 patients with peritoneal metastases only (CRPM) undergoing cytoreductive surgery with hyperthermic intraperitoneal chemoperfusion (CRS-HIPEC). Kaplan-Meier survival curves and multivariate Cox-regression models identified prognostic factors affecting survival.Major postoperative complications (Clavien-Dindo grades 3-5) occurred in 32% (CRLM) and 17% (CRPM) of patients (P = 0.08). After an estimated median follow-up from surgery of 57 mo, propensity score-adjusted median progression-free survival was 5.1 mo (CRLM) and 7.6 mo (CRPM), whereas median overall survival was 13 mo (CRLM) and 21 mo (CRPM). Multivariate Cox-regression analysis of the CRLM group identified number of liver metastases to be the only independent predictor of poor survival (hazard ratio: 2.3, P = 0.03), with a dramatic decrease in survival in patients with more than three liver metastases.Simultaneous resection of colorectal liver metastases at the time of cytoreductive surgery with hyperthermic intraperitoneal chemoperfusion for peritoneal metastases may be associated with worse survival, especially in patients with more than three liver metastases.

The comprehensive complication index (CCI) integrates all complications of the Clavien–Dindo classification (CDC) and offers a metric approach to measure morbidity. The aim of this study was to evaluate the CCI at a high-volume center for gastric cancer surgery and to compare the CCI to the conventional CDC. Clinical factors were collected from the prospective complication data of gastric cancer patients who underwent radical gastrectomy at Seoul National University Hospital from 2013 to 2014. CDC and CCI were calculated, and risk factors were investigated. Correlations and generalized linear models of hospital stay were compared between the CCI and CDC. The complication monitoring model with cumulative sum control-CCI (CUSUM-CCI) was displayed for individual surgeons, for comparisons between surgeons, and for the institution. From 1660 patients, 583 complications in 424 patients (25.5%) were identified. The rate of CDC grade IIIa or greater was 9.7%, and the overall CCI was 5.8 ± 11.7. Age, gender, Charlson score, combined resection, open method, and total gastrectomy were associated with increased CCI (p

Multivisceral resections associated with liver surgery are uncommon procedures that demand extensive surgical skills in visceral and liver surgery. Combined liver and multivisceral resections can arise in the case of an en-bloc resection of tumors that have directly infiltrated other organs, or in the circumstance of simultaneous resections of primary tumors along with distinct sites of metastatic extent. Current studies suggest that simultaneous resections can be performed safely, with outcomes comparable to or even better than staged procedures. However, these reports did not include multivisceral resections in their analysis, and the evidence concerning the feasibility and short- and long-term outcomes of these procedures is also very limited. The aim of the present chapter is to review the scientific aspects related to these complex procedures.

Patients with pseudoaneurysm in the left ventricular outflow tract (LVOT) commonly present vague and nonspecific symptoms making the diagnosis difficult. We present the case of a 37-year-old patient with two subvalvular pseudoaneurysms in whom a combined resection surgery, enlargement of the LVOT, aortic valve replacement (AVR) and aortic root replacement were performed using the technique of Cabrol.