Safety and efficacy of modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension

BACKGROUND Gastric variceal hemorrhage is one of the primary manifestations of left-sided portal hypertension(LSPH).The hemorrhage is fatal and requires safe and effective interventions.AIM To evaluate the clinical safety and efficacy of modified endoscopic ultrasound(EUS)-guided selective N-butyl-2-cyanoacrylate(NBC)injections for gastric variceal hemorrhage in LSPH.METHODS A retrospective observational study of patients with LSPH-induced gastric variceal hemorrhage was conducted.Preoperative EUS evaluations were performed.Enrolled patients were divided into modified and conventional groups according to the NBC injection technique.The final selection of NBC injection technique depended on the patients’preferences and clinical status.The technical and clinical success rates,operation time,NBC doses,perioperative complications,postoperative hospital stay,and recurrent bleeding rates were analyzed,respectively.RESULTS A total of 27 patients were enrolled.No statistically significant differences were observed between the two groups regarding baseline characteristics.In comparison to patients in the conventional group,patients in the modified group demonstrated significantly reduced NBC doses(2.0±0.6 mL vs 3.1±1.0 mL;P=0.004)and increased endoscopic operation time(71.9±11.9 min vs 22.5±6.7 min;P<0.001).Meanwhile,the two groups had no significant difference in the technical and clinical success rates,perioperative complications,postoperative hospital stay,and recurrent bleeding rates.CONCLUSION Modified EUS-guided selective NBC injections demonstrated safety and efficacy for LSPH-induced gastric variceal hemorrhage,with advantages of reduced injection dose and no radiation risk.Drawbacks were time consumption and technical challenge.

Oncologic impact of colonic stents for obstructive left-sided colon cancer

Colonic stenting has had a significant positive impact on the management of obstructive left-sided colon cancer(OLCC) in terms of both palliative treatment and bridge-to-surgery(BTS). Notably, many studies have convincingly demonstrated the effectiveness of stenting as a BTS, resulting in improvements in shortterm outcomes and quality of life, safety, and efficacy in subsequent curative surgery, and increased cost-effectiveness, whereas the safety of chemotherapy after stenting and the long-term outcomes of stenting as a BTS are controversial. Several studies have suggested an increased risk of perforation in patients receiving bevacizumab chemotherapy after colonic stenting. In addition, several pathological analyses have suggested a negative oncological impact of colonic stenting. In contrast, many recent studies have demonstrated that colonic stenting for OLCC does not negatively impact the safety of chemotherapy or long-term oncological outcomes. The updated version of the European Society of Gastrointestinal Endoscopy guidelines released in 2020 included colonic stenting as a BTS for OLCC as a recommended treatment. It should be noted that the experience of endoscopists is involved in determining technical and clinical success rates and possibly oncological outcomes. This review discusses the positive and negative impacts of colonic stenting on OLCC treatment, particularly in terms of oncology.

Predicting portal venous anomalies by left-sided gallbladder or rightsided ligamentum teres hepatis: A large scale, propensity scorematched study

BACKGROUND Right-sided ligamentum teres(RSLT)is often associated with portal venous anomalies(PVA)and is regarded as a concerning feature for hepatobiliary intervention.Most studies consider RSLT to be one of the causes of left-sided gallbladder(LGB),leading to the hypothesis that LGB must always be present with RSLT.However,some cases have shown that right-sided gallbladder(RGB)can also be present in livers with RSLT.AIM To highlight the rare variation that RSLT may not come with LGB and to determine whether ligamentum teres(LT)or gallbladder location is reliable to predict PVA.METHODS This study retrospectively assessed 8552 contrast-enhanced abdominal computed tomography examinations from 2018 to 2021[4483 men,4069 women;mean age,59.5±16.2(SD)years].We defined the surrogate outcome as major PVAs.The cases were divided into 4 subgroups according to gallbladder and LT locations.On one hand,we analyzed PVA prevalence by LT locations using gallbladder location as a controlled variable(n=36).On the other hand,we controlled LT location and computed PVA prevalence by gallbladder locations(n=34).Finally,we investigated LT location as an independent factor of PVA by using propensity score matching(PSM)and inverse probability of treatment weighting(IPTW).RESULTS We found 9 cases of RSLT present with RGB.Among the LGB cases,RSLT is associated with significantly higher PVA prevalence than typical LT[80.0%vs 18.2%,P=0.001;OR=18,95%confidence interval(CI):2.92-110.96].When RSLT is present,we found no statistically significant difference in PVA prevalence for RGB and LGB cases(88.9%vs 80.0%,P>0.99).Both PSM and IPTW yielded balanced cohorts in demographics and gallbladder locations.The RSLT group had a significantly higher PVA prevalence after adjusted by PSM(77.3%vs 4.5%,P<0.001;OR=16.27,95%CI:2.25-117.53)and IPTW(82.5%vs 4.7%,P<0.001).CONCLUSION RSLT doesn't consistently coexist with LGB.RSLT can predict PVA independently while the gallbladder location does not serve as a sufficient predictor.

Transseptal approach for catheter ablation of left-sided accessory pathways in children with Marfan syndrome:A case report

BACKGROUND Left-sided accessory pathways(APs)can be accessed with either a transaortic(TA)or transseptal approach(TS).For children with Marfan syndrome(MFS)who have aortic disease,the use of TA can aggravate the disease,making TS the best choice for these patients.CASE SUMMARY A 10-year-old girl was hospitalized because of intermittent heart palpitations and chest tightness.She was diagnosed with MFS,supraventricular tachycardia,Wolff-Parkinson-White syndrome,and left-sided AP was detected by cardiac electrophysiological.Catheter ablation was successfully performed via TS under the guidance of the Ensite system.During the follow-up,no recurrence or complications occurred.CONCLUSION The TS for catheter ablation of left-sided APs can be considered in children with MFS.Adequate evaluation and selection of the appropriate puncture site are particularly important.

Left-sided appendicitis:Review of 95 published cases and a case report

AIM:To give an overview of the literature on left-sided acute appendicitis (LSAA) associated with situs inversus totalis (SIT) and midgut malrotation (MM).METHODS:We present a new case of LSAA with SIT and a literature review of studies published in the English language on LSAA,accessed via PubMed and Google Scholar databases.RESULTS:Ninety-five published cases of LSAA were evaluated and a 25-year-old female,who presented to our clinic with left lower abdominal pain caused by LSAA,is reported.In the reviewed literature,fiftyseven patients were male and 38 were female with an age range of 8 to 82 years and a median age of 29.1 ± 15.9 years.Sixty-six patients had SIT,23 had MM,three had cecal malrotation,and two had a previously unnoted congenital abnormality.Fifty-nine patients had presentedto the hospital with left lower,14 with right lower and seven with bilateral lower quadrant pain,and seven subjects complained of left upper quadrant pain.The diagnosis was established preoperatively in 49 patients,intraoperatively in 19,and during the postoperative period in five;14 patients were aware of having this anomaly.The data of eight patients were not unavailable.Eleven patients underwent laparoscopic appendectomy,which was combined with cholecystectomy in two cases.Histopathological examination of the appendix specimens revealed adenocarcinoma in only two of 95 patients.CONCLUSION:The diagnosis of left lower quadrant pain is based on well-established clinical symptoms,physical examination and physician's experience.

Evaluation of characteristics of left-sided colorectal perfusion in elderly patients by angiography

BACKGROUND Handling of the inferior mesenteric artery(IMA)and maintaining anastomotic perfusion are important in radical resection of left-sided colorectal cancer.However,the branching of this artery and the drainage patterns of this vein vary among individuals,and the characteristics and perfusion region of this artery in elderly patients remain unclear.AIM To evaluate the characteristics and perfusion region of the IMA in elderly patients using angiography.METHODS We enrolled 154 patients(>65 years old)who underwent digital subtraction angiography of the IMA.The characteristics,bifurcation,and distribution of the IMA and termination of the anastomotic perfusion of the left colon and rectum were examined using digital subtraction angiography.Collateral arterial arches and the IMA hemoperfusion region were also recorded.Perfusion regions were cross-referenced with clinical and anatomical features by the univariate analysis.RESULTS Of 154 patients,25(16.2%)had IMA lesions.The left colic artery arose independently from the IMA in 44.2%of patients,shared a trunk with the sigmoid artery in 35.1%,shared an opening with the sigmoid and superior rectal arteries in 16.9%,and was absent in 5.1%.The IMA perfusion region stopped at the splenic flexure in 50(32.5%)patients.The collateral circulation existed in the colonic perfusion region,including the marginal artery(Drummond’s artery),the ascending branch of the left colonic artery to supply the transverse colon,and the arc of Riolan with a frequency of 100%,22.7%,and 1.9%,respectively.The IMA perfusion region was independently associated with the comorbidity of atherosclerosis,IMA atherosclerotic lesion,branching pattern,collateral circulation,and marginal artery integrity.CONCLUSION The IMA and its branches are prone to arteriosclerosis,and IMA perfusion may be interrupted at the splenic flexure in elderly patients.The applicability and precision of preoperative angiography for evaluating the IMA branching and perfusion patterns could facilitate geriatric laparoscopic left-sided colorectal cancer surgery with suspicion of poor IMA perfusion.

Right-and left-sided colorectal cancers respond differently to traditional Chinese medicine

AIM To explore the differences in the responses of left-sided colorectal cancer(LSCRC) and right-sided colon cancer(RSCC) to traditional Chinese medicine(TCM).METHODS Patients with postoperative stage I-III colorectal cancer(CRC) were enrolled and divided into the LSCRC with or without TCM and RSCC with or without TCM groups depending on the primary tumor side and TCM administration. Patients in the TCM group were given TCM for at least 6 mo. Our research adopted diseasefree survival(DFS) as the primary endpoint. We applied a Cox proportional hazards regression model for the multivariate factor analysis using Stata 12.0 and SPSS 22.0 software for data analysis.RESULTS Of the 817 patients included in our study, 617 had LSCRC(TCM group, n = 404; Non-TCM group, n = 213), and 200 had RSCC(TCM group, n = 132; NonTCM group, n = 68). The 6-year DFS for patients with LSCRC was 56.95% in the TCM group and 41.50% in the Non-TCM group(P = 0.000). For patients with RSCC, the 6-year DFS was 52.92% in the TCM group and 37.19% in the Non-TCM group(P = 0.003). Differences between LSCRC and RSCC were not statistically significant regardless of TCM ingestion.CONCLUSION Patients with either LSCRC or RSCC and who took TCM experienced longer DFS; furthermore, patients with RSCC benefited more from TCM in DFS.

Primary colon resection or Hartmann's procedure in malignant left-sided large bowel obstruction? The use of stents as a bridge to surgery

There is still significant debate regarding the best surgical treatment for malignant left-sided large bowel obstruction.Primary resection and anastomosis offers the advantages of a definite procedure without need for further surgery.Its main disadvantages are related to the increased technical challenge and to the potential higher risk of anastomotic leakage that occurs in the emergency setting.Primary resection with end colostomy(Hartmann's procedure) is considered the safer option.Tan et al compared in a systematic review and meta-analysis the use of self-expanding metallic stents(SEMS) as a bridge to surgery vs emergency surgery in the management of acute malignant left-sided large bowel obstruction.The authors concluded that the technical and clinical success rates for stenting were lower than expected.SEMS was associated with a high incidence of clinical and silent perforation.Stenting instead of loop colostomy can be recommended only if the appropriate expertise is available in the hospital.The goal of stenting,a decrease of the stoma rate,may be advocated only if the complication rates of stenting are lower than those of stoma creation in the emergency situation.Until now,this was not demonstrated in a prospective randomized trial.

Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension:A case report

BACKGROUND Left-sided portal hypertension(LSPH),also known as sinistral portal hypertension or regional portal hypertension,refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis.N-butyl-2-cyanoacrylate(NBC)has been widely used in the endoscopic hemostasis of portal hypertension,but adverse events including renal or pulmonary thromboembolism,mucosal necrosis and gastrointestinal(GI)bleeding may occur after treatment.Herein,we report successfully managing gastric variceal(GV)hemorrhage secondary to LSPH using modified endoscopic ultrasound(EUS)-guided selective NBC injections.CASE SUMMARY A 35-year-old man was referred to our hospital due to an upper GI hemorrhage.Gastroscopy revealed GV hemorrhage and computed tomography venography(CTV)confirmed LSPH.The patient requested endoscopic procedures and rejected surgical therapies including splenectomy.EUS-guided selective NBC injections were performed and confluences of gastric varices were selected as the injection sites to reduce the injection dose.The“sandwich”method using undiluted NBC and hypertonic glucose was applied.No complications occurred.The patient was followed up regularly after discharge.Three months later,the follow-up gastroscopy revealed firm gastric submucosa with no sign of NBC expulsion and the follow-up CTV showed improvements in LSPH.No recurrent GI hemorrhage was reported during this follow-up period.CONCLUSION EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.

Deep vein thrombosis in patient with left-sided inferior vena cava draining into the hemiazygos vein: A case report

BACKGROUND Abnormalities of the inferior vena cava(IVC)are uncommon,and in many cases they are asymptomatic.Even so,it is vital that clinicians be aware of such anomalies prior to surgery in affected individuals.In the present report,we describe a rare anatomical variation of the IVC.CASE SUMMARY A 66-year-old male was admitted to the hospital due to deep vein thrombosis of the right lower extremity.Upon contrast-enhanced computed tomography imaging,we found that this patient presented with a case of left-sided IVC draining into the hemiazygos vein,while his hepatic vein was directly draining into the atrium.CONCLUSION Cases of left-sided IVC can increase patient susceptibility to thromboembolism owing to the resultant changes in blood flow and/or associated vascular compression.

True left-sided gallbladder with variations of bile duct and cholecystic vein

A left-sided gallbladder without a right-sided round ligament,which is called a true left-sided gallbladder,is extremely rare.A 71-year-old woman was referred to our hospital due to a gallbladder polyp.Computed tomography(CT) revealed not only a gallbladder polyp but also the gallbladder located to the left of the round ligament connected to the left umbilical portion.CT portography revealed that the main portal vein diverged into the right posterior portal vein and the common trunk of the left portal vein and right anterior portal vein.CT cholangiography revealed that the infraportal bile duct of segment 2 joined the common bile duct.Laparoscopic cholecystectomy was performed for a gallbladder polyp,and the intraoperative finding showed that the cholecystic veins joined the round ligament.A true left-sided gallbladder is closely associated with several anomalies; therefore,surgeons encountering a true left-sided gallbladder should be aware of the potential for these anomalies.

Right- and left-sided colorectal cancersrespond differently to cetuximab

Introduction Right-sided colon cancer （RSCC） and left-sided colorectal cancer （LSCRC） differ with respect to theirbiology and genomic patterns. This study aimed to examine whether the primary tumor location is associated withthe response to cetuximab in patients with metastatic colorectal cancer （mCRC）.Methods： Patients with mCRC treated with cetuximab and standard chemotherapy as first- or second-line treatmentswere compared with randomly chosen patients who were treated with chemotherapy alone between 2005 and 2013.The main outcome measures were the overall response rate （ORR）, progression-free survival （PFS）, and overall survival （OS）.The differences in the outcome were analyzed by using the chi-squared test, Student＇s t test, and Kaplan-Meier method.Results： The treatment results of 206 patients with mCRC treated with cetuximab and standard chemotherapy asfirst- or second-line treatments were compared with those of 210 patients who were treated with chemotherapyalone. As a first-line treatment, cetuximab with chemotherapy was associated with a significantly higher ORR（49.4 % vs. 28.6 %, P = 0.005） as well as longer PFS （9.1 vs. 6.2 months, P = 0.002） and OS （28.9 vs. 20.1 months,P = 0.036） than chemotherapy alone in patients with LSCRC. However, cetuximab neither improved the ORR（36.4 % vs. 26.2 %, P = 0.349） nor prolonged PFS （5.6 vs. 5.7 months, P = 0.904） or OS （25.1 vs. 19.8 months, P = 0.553） inpatients with RSCC. As a second-line treatment, cetuximab exhibited a tendency to improve the ORR （23.5 % vs. 10.2 %,P = 0.087） and prolong PFS （4.9 vs. 3.5 months, P = 0.064）, and it significantly prolonged OS （17.1 vs. 12.4 months,P = 0.047） compared with chemotherapy alone in the patients with LSCRC. In contrast, as a second-line treatment,cetuximab neither improved the ORR （7.1 % vs. 11.4 %, P = 0.698） nor prolonged PFS （3.3 vs. 4.2 months, P = 0.761） orOS （13.4 vs. 13.0 months, P=0.652） in patients with RSCC.Conclusions： The addition of cetuximab to chemotherapy in both first- and second-line treatments of mCRC may onlybenefit patients with primary LSCRC.

Situs Inversus Totalis with Left-Sided Appendicitis: A Case Report

Introduction: Left-sided acute appendicitis (LSAA) develops in association with two types of congenital anomalies: situs inversus totalis (SIT) and midgut malrotation (MM). A Left sided appendicitis is an ambiguous and difficult diagnosis to make. Aim: To present a proven case of left-sided acute appendicitis (LSAA) associated with situs inversus totalis (SIT). Case Report: A case of Left appendicitis was evaluated in a 28-year-old Asian male, who presented to our hospital in Feb. 2016, with lower abdominal pain more on left side and suspected diverticulitis or acute appendicitis with unusual appendix location. The patient doesn’t recall any history of abdominal surgery or about situs inversus totalis, abdominal and pelvic ultrasound was done, left iliac fossa appendicitis was diagnosed, Erect chest X-ray including upper abdomen revealed dextrocardia and stomach air on right side (situs inversus totalis), the patient underwent diagnostic Laproscop and Endoscopic resection of the appendix, with no incidents, and then discharged without complications, follow visits went unremarkable. Conclusion: The diagnosis of left lower quadrant pain is based on well-established clinical symptoms, physical examination and physician’s experience.

Complicated Left-Sided Amyand’s Hernia in an 18-Month-Old Boy: A Case Report and Literature Review

The rare finding of the vermiform appendix within an inguinal hernia sac is known as Amyand’s hernia. It was first described by Claudius Amyand in 1735, in a right inguinal hernia. A much rarer find is a left-sided Amyand’s hernia. This is a report of a case of complicated left-sided Amyand’s hernia in an eighteen month old male child. He presented as an emergency with an obstructed inguino-scrotal hernia and the diagnosis of Amyand’s hernia was made intra-operatively. He made uneventful recovery after surgery. Treatment options depend on findings during operation and clinical status of the patient.

Acute pancreatitis associated left-sided portal hypertension with severe gastrointestinal bleeding treated by transcatheter splenic artery embolization:a case report and literature review

Left-sided portal hypertension(LSPH)followed by acute pancreatitis is a rare condition with most patients being asymptomatic.In cases where gastrointestinal(GI)bleeding is present,however,the condition is more complicated and the mortality is very high because of the difficulty in diagnosing and selecting optimal treatment.A successfully treated case with severe GI bleeding by transcatheter splenic artery embolization is reported in this article.The patient exhibited severe uncontrollable GI bleeding and was confirmed as gastric varices secondary to LSPH by enhanced computed tomography(CT)scan and CT-angiography.After embolization,the bleeding stopped and stabilized for the entire follow-up period without any severe complications.In conclusion,embolization of the splenic artery is a simple,safe,and effective method of controlling gastric variceal bleeding caused by LSPH in acute pancreatitis.

Comparison of Clinicopathological and Survival Features of Right and Left Colon Cancers: Experience of the Medical Oncology Department of Fez

Right-sided colon cancers (RCC) and left-sided colon cancers (LCC) have different epidemiological, physiological, pathological, genetic, and clinical characteristics, which result in differences in the course, prognosis, and outcome of disease. The objective of our study is to compare right-sided colon cancers and left-sided colon cancers regarding clinicopathological and survival characteristics. This is a retrospective study of 664 patients with colon cancer treated at the medical oncology department of Fez over a period from December 2009 to September 2020. Rectosigmoid, descending colon, and splenic flexure tumors were considered left-sided colon cancers, whereas ascending colon tumors were considered right-sided colon cancers. The Kaplan Meier method was used to estimate median survival. The study included 664 patients (female, 47%) having colon cancer with a median age of 60 years (23 - 83). Of the patients, 78.5% (n = 519) had LCC and 19.36 % (n = 128) had RCC. The rate of patients aged ≥ 65 years and the rate of patients with a family history of colon cancer was higher in the LCC patients. The proportion of poorly differentiated adenocarcinomas represented 3%, of which 63% had cancer of the right colon. There was a significantly higher proportion of higher T stage (T3-4: 62% vs 38%) in right sided tumors as compared to left sided tumors. The rate of metastatic patients was 64.1% in the RCC group and 43% in the LCC group. The median follow-up period was 14 months in the RCC group and 19 months in the LCC group with higher median overall survival in the LCC group (32 vs 21 months). We found histopathological differences between right and left sided colon cancer. Tumors on the right colon were found to be more aggressive, as expressed by poorer differentiation, higher T stage associated with a median overall survival better in left colon cancer.

Torsion of spleen and portal hypertension: Pathophysiology and clinical implications

The displacement of spleen from its normal location to other places is known as wandering spleen(WS)and is a rare disease.The repeated torsion of WS is due to the presence of long pedicle and absence/laxity of anchoring ligaments.A WS is an extremely rare cause of left-sided portal hypertension(PHT)and severe gastric variceal bleeding.Left-sided PHT usually occurs as a result of splenic vein occlusion caused by splenic torsion,extrinsic compression of the splenic pedicle by enlarged spleen,and splenic vein thrombosis.There is a paucity of data on WSrelated PHT,and these data are mostly in the form of case reports.In this review,we have analyzed the data of 20 reported cases of WS-related PHT.The mechanisms of pathogenesis,clinico-demographic profile,and clinical implications are described in this article.The majority of patients were diagnosed in the second to third decade of life(mean age:26 years),with a strong female preponderance(M:F=1:9).Eleven of the 20 WS patients with left-sided PHT presented with abdominal pain and mass.In 6 of the 11 patients,varices were detected incidentally on preoperative imaging studies or discovered intraoperatively.Therefore,pre-operative search for varices is required in patients with splenic torsion.

Rheumatic “Taussig-Bing Heart”: A Case Report

Aim: To report a case of acyanotic Taussig-Bing heart, anatomically consistent with L-transposition and rheumatic Left AV valve regurgitation associated with complete AV block in an adolescent male. Introduction: Taussig-Bing heart is one of the conotruncal malformation, characterized by double-outlet right ventricle (DORV) and a subpulmonary VSD. Embryologically, abnormal cardiac looping with malalignment of conotruncal septum result its complexity and great artery relationships. Case Report: A 14-year old acyanotic boy presented with severe left-sided AV valve regurgitation and bradycardia. ECG revealed left sided morphologic right ventricular hypertrophy (RVH) as evidenced by a loss of septal Q waves in left precordial leads suggesting ventricular inversion. X-ray chest revealed a straight upper right cardiac border due to loss of normal relationship of great vessels and cardiomegaly due to both left atrial and morphologic right ventricular enlargements suggesting a left-sided regurgitant lesion. Echocardiography revealed the ventricular inversion, primary origin of both L-transposed great arteries from the left-sided morphologic right ventricle suggesting a “double-outlet morphologic right ventricle” with “double discordance” and a subpulmonary VSD of Taussig-Bing type. The left-sided morphologic tricuspid valve is severely regurgitant due to rheumatic process resulting in heart failure which was improved with anti-failure measures and penicillin prophylaxis. Conclusion: The presence of left-sided regurgitation associated with bradycardia is a suspicion of “double discordance” and “double switch” procedure remains the mainstay of its surgical correction. Left AV valve replacement with intraventricular repair is preferred in this child since the malformation is consistent with Taussing-Bing type of DORV with L-transposition.

Left hepatic trisectionectomy for perihilar cholangiocarcinoma with a right-sided round ligament:A case report

BACKGROUND A right-sided round ligament(RSRL)is a rare,congenital anomaly of the intrahepatic portal vein,with a reported frequency of 0.2%-1.2%.For patients with perihilar cholangiocarcinoma associated with an RSRL,an accurate understanding of the vascular and biliary anatomy is indispensable.CASE SUMMARY We report a 70-year-old male with perihilar cholangiocarcinoma associated with an RSRL.After percutaneous transhepatic embolization of the left and anterior portal branches,we conducted a left trisectionectomy of the liver with extrahepatic bile duct resection and hepaticojejunostomy.The postoperative course was uneventful,and R0 resection was achieved.When the liver volume of each section was compared between 7 patients with an RSRL and 20 patients with normal portal vein anatomy,the posterior section in RSRL patients was significantly larger than that in patients with normal portal vein anatomy(median:457 mL vs 306 mL,P=0.031).In patients with perihilar cholangiocarcinoma associated with an RSRL,left trisectionectomy has several surgical advantages:(1)The posterior branch of the portal vein often ramifies independently,and the division of the portal vein is easily conducted;(2)A relatively large amount of remnant liver can be retained;and(3)The anatomy of the posterior branch of the Glissonian pedicle is similar to that in patients with normal anatomy.CONCLUSION In patients with an RSRL and perihilar cholangiocarcinoma that does not involve the posterior section,left trisectionectomy may be a favorable choice.

Sinistroposition of the gallbladder and common bile duct

BACKGROUND: Despite its rare incidence, few cases of left-side gallbladder have been already published. METHODS: We reported herein the case of a 29-year-old man with a left liver tumor in whom left lateral bisegmen- tectomy was mandatory. It represents the first description of a sinistroposition of both gallbladder and common bile duct. RESULTS: Surgical exploration revealed a left-side gall- bladder , located under the left lobe of the liver. During he- patic parenchyma dissection at the left side of the round liga- ment and the Rex recessus, the common bile duct was in- jured. Complete separation of hepatic pedicle structures showed that the upper biliary convergence passed on the left side of the Rex recessus before reaching the hepatoduo- denal ligament. CONCLUSION: Only careful dissection of the hepatoduo- denal ligament up to Rex recessus level prior to liver paren- chyma resection could avoid biliary tract injury during left lobectomy.