Portal hypertension, especially when it is caused by extrahepatic portal vein thrombosis, is commonly followed by the development of an abnormal periportal and pericholedochal variceal network, which form a portal cavernoma. This may exert extrinsic pressure on the adjacent biliary ducts and gallblader, causing morphologic abnormalities, termed portal biliopathy, which is usually leading to asymptomatic cholestasis, while less frequently it can be associated with obstructive jaundice, gallstone formation, and cholangitis. Endoscopic stone extraction can effectively treat portal biliopathy when cholangitis is associated with common bile duct stones. Portosystemic shunts are indicated in cases of disease recurrence as they can achieve regression of portal cavernoma and usually relieve symptomatic portal biliopathy. This case describes an alternative partial portosystemic shunt that utilizes the right ovarian vein as an autologous conduit for the surgical treatment of symptomatic portal biliopathy.

Konstantinos Vasiliadis

Guido Engelmann

Peter  Sauer

J&#252;rgen Weitz

Jan Schmidt

Right Porto-Ovarian H-Shunt for the Surgical Treatment of Symptomatic Portal Biliopathy: A Case Report and Literature Review

<i>Backgrounds and Study Aims</i>. Common bile duct (CBD) injury is one of the most serious complications of laparoscopic cholecystectomy (LC). Misidentification of the CBD during
dissection of the Calot's triangle can lead to such injuries. The aim of the authors in this study is to present a new safe triangle of dissection. <i>Patients and Method</i>. 501 patients under went LC in the following approach; The cystic artery is identified and mobilized from the gall bladder (GB) medial wall down towards the cystic duct which would simultaneously divide the medial GB peritoneal attachment. This is then followed by dividing the lateral peritoneal attachment. The GB will be unfolded and the borders of the triangle of safety (TST) are achieved: cystic artery medially, cystic duct laterally and the gallbladder wall superiorly. The floor of the triangle is then divided to delineate both cystic duct and artery in an area relatively far from CBD. <i>Results</i>. There were little significant immediate or delayed complications. The mean operating time was 68 minutes, nearly equivalent to the conventional method. <i>Conclusions</i>. Dissection at TST appears to be a safe procedure which clearly demonstrates the cystic duct and may help to reduce the CBD injuries.

Abdulrahman F. M. S. Almutairi

Yousef A. M. S. Hussain

Triangle of Safety Technique: A New Approach to Laparoscopic Cholecystectomy

Although laparoscopic cholecystectomy (LC) has been widely accepted as the standard of care, it continues to have a higher complication rate than open cholecystectomy. Bile duct injury with LC has often been attributed to surgical inexperience, but it is also clear that aberrant bile ducts are present in a significant number of patients who sustain biliary injuries during these procedures. We present three cases of right sectoral hepatic duct injuries which occurred during LC and provide a discussion of the conditions which are likely to lead to these injuries, as part of a strategy to prevent them.

Nitin Babel

Sujit V. Sakpal

Prakash Paragi

Jason Wellen

Stephen Feldman

Ronald S. Chamberlain

Iatrogenic Bile Duct Injury Associated with Anomalies of the Right Hepatic Sectoral Ducts: A Misunderstood and Underappreciated Problem

Pancreatic fistula continues to be a common complication following PD. This study seeks to identify clinical factors which may predict pancreatic fistula (PF) and evaluate the effect of PF on outcomes following pancreaticoduodenectomy (PD).  We performed a retrospective analysis of a clinical database at an academic tertiary care hospital with a high volume of pancreatic surgery. Five hundred ten consecutive patients underwent PD, and PF occurred in 46 patients (9%).  Perioperative mortality of patients with PF was 0%. Forty-five of 46 PF (98%) closed without reoperation with a mean time to closure of 34 days. Patients who developed PF showed a higher incidence of wound infection, intra-abdominal abscess, need for reoperation, and hospital length of stay. Multivariate analysis demonstrated an invaginated pancreatic anastomosis and closed suction intraperitoneal drainage were associated with PF whereas a diagnosis of chronic pancreatitis and endoscopic stenting conferred protection. Development of PF following PD in this series was predicted by gender, preoperative stenting, pancreatic anastomotic technique, and pancreas pathology. Outcomes in patients with PF are remarkable for a higher rate of septic complications, longer hospital stays, but in this study, no increased mortality.

C. Max Schmidt

Jennifer Choi

Emilie S. Powell

Constantin T. Yiannoutsos

Nicholas J. Zyromski

Attila Nakeeb

Henry A. Pitt

Eric A. Wiebke

James A. Madura

Keith D. Lillemoe

Pancreatic Fistula Following Pancreaticoduodenectomy: Clinical Predictors and Patient Outcomes

<i  >Background/Aims</i>. At present, there is no simple test for predicting severity in acute pancreatitis. We investigated the use of an assay of soluble E-cadherin (sE-cadherin). <i  >Methods</i>. Concentrations of sE-cadherin, from 19 patients with mild acute pancreatitis, 7 patients with severe acute pancreatitis, 11 patients with other acute gastrointestinal pathologies, and 12 healthy subjects were measured using a commercially available sandwich ELISA kit based on two monoclonal antibodies specific to the extracellular fragment of human E-cadherin. Measurements were made at 12 hours or less from onset of pain and also at 24 and 48 hours after onset of pain. <i  >Results</i>. Mean (standard deviation) concentration of sE-cadherin in patients with severe acute pancreatitis at <svg style="vertical-align:-0.30096pt;width:10.825px;" id="M1" height="8.8500004" version="1.1" viewBox="0 0 10.825 8.8500004" width="10.825"  xmlns="http://www.w3.org/2000/svg">
	<g transform="matrix(1.25,0,0,-1.25,0,8.85)">
		<g transform="translate(72,-64.92)">
			<text transform="matrix(1,0,0,-1,-71.95,65.27)">
				<tspan style="font-size: 12.50px; " x="0" y="0">&lt;</tspan>
			</text>

		</g>
	</g>
</svg>12 hours was 17780&#x2009;ng/mL (7853), significantly higher than that of healthy volunteers 5180&#x2009;ng/mL (1350), <svg style="vertical-align:-0.27588pt;width:63.962502px;" id="M2" height="11.0375" version="1.1" viewBox="0 0 63.962502 11.0375" width="63.962502"  xmlns="http://www.w3.org/2000/svg">
	<g transform="matrix(1.25,0,0,-1.25,0,11.0375)">
		<g transform="translate(72,-63.17)">
			<text transform="matrix(1,0,0,-1,-71.95,63.5)">
				<tspan style="font-size: 12.50px; " x="0" y="0">𝑃</tspan>
				<tspan style="font-size: 12.50px; " x="10.890113" y="0">=</tspan>
				<tspan style="font-size: 12.50px; " x="22.930502" y="0">.</tspan>
				<tspan style="font-size: 12.50px; " x="26.056252" y="0">0</tspan>
				<tspan style="font-size: 12.50px; " x="32.307751" y="0">0</tspan>
				<tspan style="font-size: 12.50px; " x="38.559254" y="0">3</tspan>
				<tspan style="font-size: 12.50px; " x="44.810753" y="0">9</tspan>
			</text>

		</g>
	</g>
</svg>, patients with other gastrointestinal pathologies 7358&#x2009;ng/mL (6655), <svg style="vertical-align:-0.17555pt;width:63.962502px;" id="M3" height="10.9125" version="1.1" viewBox="0 0 63.962502 10.9125" width="63.962502"  xmlns="http://www.w3.org/2000/svg">
	<g transform="matrix(1.25,0,0,-1.25,0,10.9125)">
		<g transform="translate(72,-63.27)">
			<text transform="matrix(1,0,0,-1,-71.95,63.5)">
				<tspan style="font-size: 12.50px; " x="0" y="0">𝑃</tspan>
				<tspan style="font-size: 12.50px; " x="10.890113" y="0">=</tspan>
				<tspan style="font-size: 12.50px; " x="22.930502" y="0">.</tspan>
				<tspan style="font-size: 12.50px; " x="26.056252" y="0">0</tspan>
				<tspan style="font-size: 12.50px; " x="32.307751" y="0">0</tspan>
				<tspan style="font-size: 12.50px; " x="38.559254" y="0">7</tspan>
				<tspan style="font-size: 12.50px; " x="44.810753" y="0">3</tspan>
			</text>

		</g>
	</g>
</svg>, and also significantly higher than that of patients with mild pancreatitis, 7332&#x2009;ng/mL (2843), <svg style="vertical-align:-0.27588pt;width:63.962502px;" id="M4" height="11.0375" version="1.1" viewBox="0 0 63.962502 11.0375" width="63.962502"  xmlns="http://www.w3.org/2000/svg">
	<g transform="matrix(1.25,0,0,-1.25,0,11.0375)">
		<g transform="translate(72,-63.17)">
			<text transform="matrix(1,0,0,-1,-71.95,63.5)">
				<tspan style="font-size: 12.50px; " x="0" y="0">𝑃</tspan>
				<tspan style="font-size: 12.50px; " x="10.890113" y="0">=</tspan>
				<tspan style="font-size: 12.50px; " x="22.930502" y="0">.</tspan>
				<tspan style="font-size: 12.50px; " x="26.056252" y="0">0</tspan>
				<tspan style="font-size: 12.50px; " x="32.307751" y="0">0</tspan>
				<tspan style="font-size: 12.50px; " x="38.559254" y="0">1</tspan>
				<tspan style="font-size: 12.50px; " x="44.810753" y="0">9</tspan>
			</text>

		</g>
	</g>
</svg>. <i  >Discussion</i>. Serum sE-cadherin could be an early (within 12 hours) objective marker of severity in acute pancreatitis. This molecule warrants further investigation in the form of a large multicentre trial.


A. Sewpaul

J. J. French

T. K. Khoo

M. Kernohan

J. A. Kirby

R. M. Charnley

Soluble E-Cadherin: An Early Marker of Severity in Acute Pancreatitis

The rupture of retroperitoneal varices is a rare and catastrophic complication of portal hypertension. We describe a case of this nature, the first in Brazilian medical literature, and also reviewing all previous 34 cases. We systematically analyzed all therapeutic approach and propose a management algorithm for diagnosis and treatment of this lethal condition. The majority of the patients presented with abdominal pain, distention and hypotension, and developed hemorrhagic shock. Rupture of retroperitoneal varices can be properly managed if an early diagnosis is made and surgery is performed promptly, which is the only effective treatment. Arteriography should be used when the suspicion is of rupture of hepatocellular carcinoma.

Igor Rafael Sincos

Grace Mulatti

Sheila Mulatti

Ilana Cristina Sincos

Sergio Q. Belczak

Valdir Zamboni

Hemoperitoneum in a Cirrhotic Patient Due to Rupture of Retroperitoneal Varix

<i  >Background</i>. The liver has an enormous capacity to regenerate itself. The aim of this study was to evaluate whether the regeneration is due to hypertrophy or hyperplasia of the remnant liver after extended resection and whether a portosystemic shunt is beneficial. <i  >Material and methods</i>. An extended left hemihepatectomy was performed in 25 pigs, and in 14 after performing a portosystemic shunt. During follow up, liver regeneration was estimated by macroscopic markers such as liver volume and size of the portal fields <svg style="vertical-align:-1.95624pt;width:40.950001px;" id="M1" height="16.2125" version="1.1" viewBox="0 0 40.950001 16.2125" width="40.950001"  xmlns="http://www.w3.org/2000/svg">
	<g transform="matrix(1.25,0,0,-1.25,0,16.2125)">
		<g transform="translate(72,-59.03)">
			<text transform="matrix(1,0,0,-1,-71.95,61.03)">
				<tspan style="font-size: 12.50px; " x="0" y="0">[</tspan>
				<tspan style="font-size: 12.50px; " x="4.1634989" y="0">m</tspan>
				<tspan style="font-size: 12.50px; " x="13.890833" y="0">m</tspan>
			</text>

			<text transform="matrix(1,0,0,-1,-48.33,66.03)">
				<tspan style="font-size: 8.75px; " x="0" y="0">2</tspan>
			</text>

			<text transform="matrix(1,0,0,-1,-43.46,61.03)">
				<tspan style="font-size: 12.50px; " x="0" y="0">]</tspan>
			</text>

		</g>
	</g>
</svg> as well as the amount of hepatocytes per portal field and the amount of hepatocytes per <svg style="vertical-align:-0.0pt;width:30.5375px;" id="M2" height="13.775" version="1.1" viewBox="0 0 30.5375 13.775" width="30.5375"  xmlns="http://www.w3.org/2000/svg">
	<g transform="matrix(1.25,0,0,-1.25,0,13.775)">
		<g transform="translate(72,-60.98)">
			<text transform="matrix(1,0,0,-1,-71.95,61.03)">
				<tspan style="font-size: 12.50px; " x="0" y="0">m</tspan>
				<tspan style="font-size: 12.50px; " x="9.727334" y="0">m</tspan>
			</text>

			<text transform="matrix(1,0,0,-1,-52.5,66.03)">
				<tspan style="font-size: 8.75px; " x="0" y="0">2</tspan>
			</text>

		</g>
	</g>
</svg>. <i  >Results</i>. Regardless of the operation procedure, the volume of the remnant liver increased about 2.5 fold at the end of the first week after resection. The size of the portal fields increased significantly as well as the number of hepatocytes in the portal fields. Interestingly, the number of  hepatocytes per <svg style="vertical-align:-0.0pt;width:30.5375px;" id="M3" height="13.775" version="1.1" viewBox="0 0 30.5375 13.775" width="30.5375"  xmlns="http://www.w3.org/2000/svg">
	<g transform="matrix(1.25,0,0,-1.25,0,13.775)">
		<g transform="translate(72,-60.98)">
			<text transform="matrix(1,0,0,-1,-71.95,61.03)">
				<tspan style="font-size: 12.50px; " x="0" y="0">m</tspan>
				<tspan style="font-size: 12.50px; " x="9.727334" y="0">m</tspan>
			</text>

			<text transform="matrix(1,0,0,-1,-52.5,66.03)">
				<tspan style="font-size: 8.75px; " x="0" y="0">2</tspan>
			</text>

		</g>
	</g>
</svg> remained the same. <i  >Conclusion</i>. After extended resection, liver regeneration was achieved by an extensive and significant hyperplasia of hepatocytes within the preexisting portal fields and not by de novo synthesis of new portal fields. However, there was no difference in liver regeneration regarding the operation procedure performed with or without portosystemic shunt.

Ruth Ladurner

Frank Traub

Martin Schenk

Alfred K&#246;nigsrainer

J&#246;rg Glatzle

Cellular Liver Regeneration after Extended Hepatic Resection in Pigs

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