A Case of Gastrointestinal Stromal Tumour (GIST) in the Duodenum in a Young Adult.

Gastrointestinal stromal tumours (GISTs) are rare gastrointestinal (GI) malignancies, but the most prevalent mesenchymal tumours of the GI tract arise from the interstitial cells of Cajal. They account for 1-3% of all GI malignancies, and only 3-5% of all cases of GIST are located at the duodenal. We present a case of a young adult who presented to the ED with symptoms of GI bleeding.

Assessment of inter-centre agreement across multidisciplinary team meetings for patients with retroperitoneal sarcoma.

BACKGROUND: Decision-making in the management of patients with retroperitoneal sarcoma is complex and requires input from a number of different specialists. The aim of this study was to evaluate the levels of agreement in terms of resectability, treatment allocation, and organs proposed to be resected across different retroperitoneal sarcoma multidisciplinary team meetings. METHODS: The CT scans and clinical information of 21 anonymized retroperitoneal sarcoma patients were sent to all of the retroperitoneal sarcoma multidisciplinary team meetings in Great Britain, which were asked to give an opinion about resectability, treatment allocation, and organs proposed to be resected. The main outcome was inter-centre reliability, which was quantified using overall agreement, as well as the chance-corrected Krippendorff's alpha statistic. Based on the latter, the level of agreement was classified as: 'slight' (0.00-0.20), 'fair' (0.21-0.40), 'moderate' (0.41-0.60), 'substantial' (0.61-0.80), or 'near-perfect' (>0.80). RESULTS: Twenty-one patients were reviewed at 12 retroperitoneal sarcoma multidisciplinary team meetings, giving a total of 252 assessments for analysis. Consistency between centres was only 'slight' to 'fair', with rates of overall agreement and Krippendorff's alpha statistics of 85.4 per cent (211 of 247) and 0.37 (95 per cent c.i. 0.11 to 0.57) for resectability; 80.4 per cent (201 of 250) and 0.39 (95 per cent c.i. 0.33 to 0.45) for treatment allocation; and 53.0 per cent (131 of 247) and 0.20 (95 per cent c.i. 0.17 to 0.23) for the organs proposed to be resected. Depending on the centre that they had attended, 12 of 21 patients could either have been deemed resectable or unresectable, and 10 of 21 could have received either potentially curative or palliative treatment. CONCLUSIONS: Inter-centre agreement between retroperitoneal sarcoma multidisciplinary team meetings was low. Multidisciplinary team meetings may not provide the same standard of care for patients with retroperitoneal sarcoma across Great Britain.

Immediate surgery compared with short-course neoadjuvant gemcitabine plus capecitabine, FOLFIRINOX, or chemoradiotherapy in patients with borderline resectable pancreatic cancer (ESPAC5): a four-arm, multicentre, randomised, phase 2 trial.

BACKGROUND: Patients with borderline resectable pancreatic ductal adenocarcinoma have relatively low resection rates and poor survival despite the use of adjuvant chemotherapy. The aim of our study was to establish the feasibility and efficacy of three different types of short-course neoadjuvant therapy compared with immediate surgery. METHODS: ESPAC5 (formerly known as ESPAC-5f) was a multicentre, open label, randomised controlled trial done in 16 pancreatic centres in two countries (UK and Germany). Eligible patients were aged 18 years or older, with a WHO performance status of 0 or 1, biopsy proven pancreatic ductal adenocarcinoma in the pancreatic head, and were staged as having a borderline resectable tumour by contrast-enhanced CT criteria following central review. Participants were randomly assigned by means of minimisation to one of four groups: immediate surgery; neoadjuvant gemcitabine and capecitabine (gemcitabine 1000 mg/m2 on days 1, 8, and 15, and oral capecitabine 830 mg/m2 twice a day on days 1-21 of a 28-day cycle for two cycles); neoadjuvant FOLFIRINOX (oxaliplatin 85 mg/m2, irinotecan 180 mg/m2, folinic acid given according to local practice, and fluorouracil 400 mg/m2 bolus injection on days 1 and 15 followed by 2400 mg/m2 46 h intravenous infusion given on days 1 and 15, repeated every 2 weeks for four cycles); or neoadjuvant capecitabine-based chemoradiation (total dose 50·4 Gy in 28 daily fractions over 5·5 weeks [1·8 Gy per fraction, Monday to Friday] with capecitabine 830 mg/m2 twice daily [Monday to Friday] throughout radiotherapy). Patients underwent restaging contrast-enhanced CT at 4-6 weeks after neoadjuvant therapy and underwent surgical exploration if the tumour was still at least borderline resectable. All patients who had their tumour resected received adjuvant therapy at the oncologist's discretion. Primary endpoints were recruitment rate and resection rate. Analyses were done on an intention-to-treat basis. This trial is registered with ISRCTN, 89500674, and is complete. FINDINGS: Between Sept 3, 2014, and Dec 20, 2018, from 478 patients screened, 90 were randomly assigned to a group (33 to immediate surgery, 20 to gemcitabine plus capecitabine, 20 to FOLFIRINOX, and 17 to capecitabine-based chemoradiation); four patients were excluded from the intention-to-treat analysis (one in the capecitabine-based chemoradiotherapy withdrew consent before starting therapy and three [two in the immediate surgery group and one in the gemcitabine plus capecitabine group] were found to be ineligible after randomisation). 44 (80%) of 55 patients completed neoadjuvant therapy. The recruitment rate was 25·92 patients per year from 16 sites; 21 (68%) of 31 patients in the immediate surgery and 30 (55%) of 55 patients in the combined neoadjuvant therapy groups underwent resection (p=0·33). R0 resection was achieved in three (14%) of 21 patients in the immediate surgery group and seven (23%) of 30 in the neoadjuvant therapy groups combined (p=0·49). Surgical complications were observed in 29 (43%) of 68 patients who underwent surgery; no patients died within 30 days. 46 (84%) of 55 patients receiving neoadjuvant therapy were available for restaging. Six (13%) of 46 had a partial response. Median follow-up time was 12·2 months (95% CI 12·0-12·4). 1-year overall survival was 39% (95% CI 24-61) for immediate surgery, 78% (60-100) for gemcitabine plus capecitabine, 84% (70-100) for FOLFIRINOX, and 60% (37-97) for capecitabine-based chemoradiotherapy (p=0·0028). 1-year disease-free survival from surgery was 33% (95% CI 19-58) for immediate surgery and 59% (46-74) for the combined neoadjuvant therapies (hazard ratio 0·53 [95% CI 0·28-0·98], p=0·016). Three patients reported local disease recurrence (two in the immediate surgery group and one in the FOLFIRINOX group). 78 (91%) patients were included in the safety set and assessed for toxicity events. 19 (24%) of 78 patients reported a grade 3 or worse adverse event (two [7%] of 28 patients in the immediate surgery group and 17 [34%] of 50 patients in the neoadjuvant therapy groups combined), the most common of which were neutropenia, infection, and hyperglycaemia. INTERPRETATION: Recruitment was challenging. There was no significant difference in resection rates between patients who underwent immediate surgery and those who underwent neoadjuvant therapy. Short-course (8 week) neoadjuvant therapy had a significant survival benefit compared with immediate surgery. Neoadjuvant chemotherapy with either gemcitabine plus capecitabine or FOLFIRINOX had the best survival compared with immediate surgery. These findings support the use of short-course neoadjuvant chemotherapy in patients with borderline resectable pancreatic ductal adenocarcinoma. FUNDING: Cancer Research UK.

Identification of "Digital Sarcopenia" Can Aid the Detection of Pancreatic Exocrine Insufficiency and Malnutrition Assessment in Patients with Suspected Pancreatic Pathology.

BACKGROUND: Pancreatic exocrine insufficiency (PEI) and subsequent malnutrition can be difficult to diagnose but lead to sarcopenia and increased mortality and morbidity even in benign disease. Digital skeletal muscle analysis has been increasingly recognised as a tool to diagnose sarcopenia. OBJECTIVE: The aim of the study was to assess the prevalence of sarcopenia in patients with PEI secondary to benign disease using novel skeletal muscle recognition software. METHODS: Prospective recruitment of patients referred for endoscopic ultrasound (EUS) with suspected pancreatic pathology. Patients with suspected pancreatic cancer on initial computed tomography (CT) were excluded. The diagnosis of chronic pancreatitis (CP) was based on CT and EUS findings. PEI was assessed with faecal elastase-1. Digital measurement of skeletal muscle mass identified sarcopenia, with demographic and comorbidity data also collected. RESULTS: PEI was identified in 45.1% (46/102) of patients recruited, and 29.4% (30/102) had changes of CP. Sarcopenia was significantly more prevalent in PEI 67.4% (31/46) than no-PEI 37.5% (21/56) (37.5%), regardless of CP changes (p < 0.003). The prevalence of sarcopenia (67% vs. 35%; p = 0.02) and sarcopenic obesity (68.4% vs. 25%; p = 0.003) was significantly higher when PEI was present without a radiological diagnosis of CP. Multivariate analysis identified sarcopenia and diabetes to be independently associated with PEI (odds ratio 4.8 and 13.8, respectively, p < 0.05). CONCLUSION: Sarcopenia was strongly associated with PEI in patients undergoing assessment for suspected benign pancreatic pathology. Digital skeletal muscle assessment can be used as a tool to aid identification of sarcopenia in patients undergoing CT scan for pancreatic symptoms.

Calcifying fibrous tumour-a rare cause of anaemia.

Calcifying fibrous tumour (CFT) is a rare benign tumour with non-specific anatomical distribution. We describe a case of a patient who presented with chronic generalised fatigue secondary to anaemia. Her symptoms did not improve while being on oral iron replacement therapy. Further endoscopic investigations were unremarkable. She had a computed tomography scan showing masses in the right pleural base and in the spleen. She then underwent splenic biopsy that only showed inflammatory changes. As her symptoms persisted, she was worked up for elective laparoscopic splenectomy during which she was found to have multiple peritoneal deposits. Biopsies were taken and the splenectomy was abandoned. The biopsies eventually showed changes consistent with CFT. This was conclusive for diagnosis of multifocal CFT.

Yield of testing for micronutrient deficiencies associated with pancreatic exocrine insufficiency in a clinical setting: An observational study.

BACKGROUND: Pancreatic exocrine insufficiency (PEI) can be difficult to diagnose and causes maldigestion symptoms and malabsorption. There has been a number of studies that have identified PEI associated micronutrient deficiencies (PEI-MD), however there is variation in both the frequency and type of PEI-MD reported, with the majority of studies including patients with PEI due to chronic pancreatitis (CP) or CP without PEI. There is a paucity of information regarding the prevalence of PEI-MD in patients with PEI without CP and the yield of testing for PEI-MD in a clinical setting in patients with suspected benign pancreatic diseases. AIM: To prospectively assess the yield and type of PEI-MD in patients with and without PEI secondary to benign pancreatic disease. METHODS: Patients investigated for maldigestion symptoms with Faecal Elastase-1 (FEL-1) and suspected or proven benign pancreatic disease were prospectively identified. At the time of FEL-1 testing, serum samples were taken for micronutrients identified by previous studies as PEI-MD: prealbumin, retinol binding protein, copper, zinc, selenium, magnesium and later in the study lipid adjusted vitamin E. FEL-1 was recorded, with a result < 200 µg/g considered diagnostic of PEI. Patients underwent computed tomography (CT) imaging when there was a clinical suspicion of CP, a new diagnosis of PEI recurrent, pancreatic type pain (epigastric abdominal pain radiating to back with or without previous acute pancreatitis attacks) or weight loss. RESULTS: After exclusions, 112 patients were recruited that underwent testing for FEL-1 and PEI-MD. PEI was identified in 41/112 (36.6%) patients and a pancreatic CT was performed in 82 patients. Overall a PEI-MD was identified in 21/112 (18.8%) patients. The yield of PEI-MD was 17/41 (41.5%) if PEI was present which was significantly higher than those without 4/71 (5.6%) (P = 0.0001). The yield of PEI-MD was significantly higher when PEI and CP were seen together 13/22 (59.1%) compared to CP without PEI and PEI without CP (P < 0.03). Individual micronutrient assessment showed a more frequent occurrence of prealbumin 8/41 (19.5%), selenium 6/41 (14.6%) and magnesium 5/41 (12.2%) deficiency when PEI was present (< 0.02). The accuracy of using the significant micronutrients identified in our cohort as a predictor of PEI showed a positive predictive value of 80%-85.7% [95% confidence interval (CI): 38%-100%] and a low sensitivity of 9.8%-19.5% [95% CI: 3.3%-34.9%]. CONCLUSION: Testing for PEI-MD in patients with suspected pancreatic disease has a high yield, specifically when PEI and CP are found together. PEI-MD testing should include selenium, magnesium and prealbumin.

Pancreatic enzyme replacement therapy following surgery for pancreatic cancer: An exploration of patient self-management.

BACKGROUND: For those diagnosed with pancreatic cancer, ill-addressed pancreatic exocrine insufficiency (PEI) following surgery can result in malnutrition related complications that may impact on predict mortality and morbidity. The use of pancreatic enzyme replacement therapy (PERT) is recommended and often demands a degree of patient self-management. Understanding more about how this treatment is managed is fundamental to optimising care. OBJECTIVE: This study aimed to explore patient self-management of PERT following surgery for pancreatic cancer. METHODS: Semi-structured interviews were conducted with nine participants. Eligible participants included adult patients who had undergone surgery for a malignancy in the pancreatic region and were prescribed PERT post-operatively. Inductive thematic analysis was used to analyse our findings. RESULTS: Data analysis revealed three overarching themes; the role of professional support, factors influencing decisions to use PERT in symptom management and the challenges of socializing. The difficulties negotiated by participants were considerable as they struggled with the complexities of PERT. Symptom management and subsequently reported physical repercussions and undesirable social implications were problematic. Professional support was largely inconsistent and relinquished prematurely following discharge. Consequently, this impacted on how PERT was self-managed. CONCLUSION: Enabling patients to appropriately self-manage PERT may lessen the post-treatment burden. Our findings suggest that support should continue throughout the recovery phase and should address the patient's 'self-management journey'. Intervention by healthcare professionals, such as a specialist dietitian is likely to be beneficial. Furthermore there are focal issues, primarily explicit education and appropriately timed information that require consideration by those developing and delivering services.

Autoimmune pancreatitis with concomitant autoimmune haemolytic anaemia.

Autoimmune pancreatitis (AIP) is an infrequent cause of acute pancreatitis, being more commonly associated with chronic pancreatitis. AIP can be associated with other autoimmune manifestations, including Sjögren's, inflammatory bowel disease, primary biliary cirrhosis, rheumatoid arthritis, hypothyroidism and sarcoidosis. Rarely, concurrent autoimmune haemolytic anaemia (AIHA) is observed, as seen in our case report of a 33-year-old postpartum woman.

Atypical presentation of a spontaneous coeliac artery dissection resulting in jejunal ischaemia.

We describe a case of a 59-year-old man with no significant medical history apart from a hiatus hernia and depression who presented with periumbilical pain which woke him at night. Before this he had 6 weeks of generalised abdominal pain. Blood tests were relatively normal and CT revealed some ill-defined stranding around the coeliac artery. He was diagnosed with a spontaneous coeliac artery dissection. Given the complexity of the case, a multidisciplinary team approach was adopted. He was managed conservatively and improved significantly over the next few days. Further investigations confirmed ischaemic changes to the distal duodenum and proximal jejunum. He has since been followed-up with CT scans and has had no further episodes 12 months from his initial admission.

Successful management of necrotizing pancreatitis by percutaneous necrosectomy after orthotopic liver transplant for paracetamol induced acute liver failure: a case report.

OBJECTIVES: Acute pancreatitis, which can develop after any whole-organ transplant, is often associated with immunosuppression. Pancreatitis that complicates a liver transplant can be a significant problem that results in a high mortality rate. MATERIALS AND METHODS: We describe the successful use of minimally invasive techniques to treat severe acute pancreatitis. To our knowledge, this is the first reported case in which major laparotomy was precluded by the use of percutaneous necrosectomy to manage necrotizing pancreatitis in a liver transplant recipient. We also briefly review the published literature on severe acute pancreatitis in liver transplant recipients. RESULTS: Our patient, who had a Model for End- Stage Liver Disease score of 39 when transplanted and an Acute Physiology and Chronic Health Evaluation II score of 19 when infected necrosis in his pancreas was diagnosed, recovered completely after 92 days of hospitalization. He underwent 2 percutaneous drainage procedures and 3 percutaneous necrosectomies to treat his pancreatic complication. A review of the literature revealed that severe acute pancreatitis significantly increases morbidity and mortality in liver transplant recipients. Unlike necrotizing pancreatitis, which develops outside the context of liver transplant where there is a distinct shift towards minimally invasive procedures, infected necrosis associated with fulminant liver failure or a liver transplant is usually treated with open necrosectomy. CONCLUSIONS: Severe acute pancreatitis in liver transplant recipients should be managed exactly as it is in patients who have not received a liver transplant. Anatomically guided minimally invasive necrosectomy appears to be beneficial, especially when patients are critically unwell, as they are following a liver transplant.

A simple prophylaxis regimen for MRSA: its impact on the incidence of infection in patients undergoing liver resection.

INTRODUCTION: Methicillin-resistant Staphylococcus aureus (MRSA) infection has increased at an alarming rate in the recent past and has major cost implications. The aim of this study is to assess the impact of a policy of pre-operative MRSA prophylaxis on the incidence of MRSA infection in patients undergoing liver resection. PATIENTS AND METHODS: A total of 585 patients underwent hepatectomy in a tertiary referral centre between January 2000 and September 2005. In September 2003, a policy of MRSA prophylaxis (nasal mupirocin and triclosan wash for 5 days) was introduced within this unit. Demographic, pathological and outcome data were compared between the pre- and post-MRSA prophylaxis cohorts. RESULTS: The prevalence of MRSA infection prior to initiating the prophylaxis protocol was 29 patients (8.3%) and this fell to 9 patients (3.8%; P = 0.029). Furthermore, patients who had MRSA-related infection had a higher incidence of additional complications compared to the rest of the cohort (P = 0.001). Total cost savings incurred as a result of this protocol over the past 2 years has been approximated at 28,893 pounds. CONCLUSIONS: Introduction of a simple MRSA prophylaxis policy has had a significant reduction on the incidence MRSA-related infection within our patient population, leading to reduced morbidity and cost saving to the UK National Health Service.

Right hepatic trisectionectomy for hepatobiliary diseases: results and an appraisal of its current role.

OBJECTIVE: To assess the results of 275 patients undergoing right hepatic trisectionectomy and to clarify its current role. SUMMARY BACKGROUND DATA: Right hepatic trisectionectomy is considered one of the most extensive liver resections, and few reports have described the long-term results of the procedure. METHODS: Short- and long-term outcomes of 275 consecutive patients who underwent right hepatic trisectionectomy from January 1993 to January 2006 were analyzed. RESULTS: Of the 275 patients, 160 had colorectal metastases, 49 had biliary tract cancers, 20 had hepatocellular carcinomas, 20 had other metastatic tumors, and 12 had benign diseases. Fourteen of the 275 patients underwent right hepatic trisectionectomy as part of auxiliary liver transplantation for acute liver failure and were excluded. Concomitant procedures were carried out in 192 patients: caudate lobectomy in 45 patients, resection of tumors from the liver remnant in 57 patients, resection of the extrahepatic biliary tree in 45 patients, and lymphadenectomy in 45 patients. One-, 3-, 5-, and 10-year survivals were 74%, 54%, 43%, and 36%, respectively. Overall hospital morbidity and 30-day and in-hospital mortalities were 41%, 7%, and 8%, respectively. Survivals for individual tumor types were acceptable, with 5-year survivals for colorectal metastasis and cholangiocarcinoma being 38% and 32%, respectively. Multivariate analysis disclosed the amount of intraoperative blood transfusion to be the sole independent predictor for the development of hospital morbidity. Age over 70 years, preoperative bilirubin levels, and the development of postoperative renal failure were found to be independent predictors of long-term survival. CONCLUSION: Right hepatic trisectionectomy remains a challenging procedure. The outcome is not influenced by additional concomitant resection of tumors from the planned liver remnant. Caution must be taken when considering patients older than 70 years for such resections.

Preoperative prognostic score for predicting survival after hepatic resection for colorectal liver metastases.

BACKGROUND: Despite indications for resection of colorectal liver metastases having expanded, debate continues about identifying patients that may benefit from surgery. METHODS: Clinicopathologic data from a total of 700 patients was gathered between January 1993 and January 2006 from a prospectively maintained dataset. Of these, 687 patients underwent resection for colorectal liver metastases. RESULTS: The median age of patient was 64 years and 36.8% of patients had synchronous disease. The overall 5-year survival was 45%. The presence of an inflammatory response to tumor (IRT), defined by an elevated C-reactive protein (>10 mg/L) or a neutrophil/lymphocyte ratio of >5:1, was noted in 24.5% of cases. Only the number of metastases and the presence or absence of an IRT influenced both overall and disease-free survival on multivariable analysis. A preoperative prognostic score was derived: 0 = less than 8 metastases and absence of IRT; 1 = 8 or more metastases or IRT, and 2 = 8 or more metastases and IRT-from the results of the multivariable analysis. The 5-year survival of those scoring 0 was 49% compared with 34% for those scoring 1. None of the patients that scored 2 were alive at 5 years. CONCLUSION: The preoperative prognostic score is a simple and effective system allowing preoperative stratification.

Indication for treatment and long-term outcome of focal nodular hyperplasia.

INTRODUCTION: Unlike malignant liver tumours, the indications for hepatic resection for benign disease are not well defined. This is particularly true for focal nodular hyperplasia (FNH). Here we summarize a single-centre experience of the diagnosis and management of FNH. MATERIALS AND METHODS: Using a prospectively collected database, a retrospective analysis of consecutive patients who were managed at our centre for FNH between January 1997 and December 2006 was performed. RESULTS: The cohort was divided into two groups of patients: those who were managed surgically (n=15) and those managed conservatively (n=37). There was no correlation between tumour size and number of lesions with oral contraceptive use (p=0.07 and 0.90, respectively) and pregnancy (p=0.45 and 0.60, respectively). However, tumour size (p=0.006) and number of lesions (p=0.02) were associated with the occurrence of pain in these patients. Pain was the commonest symptom of patients (13/15) who were managed surgically. All patients underwent radiological imaging before diagnosis. The sensitivities of ultrasound, CT scanning and MRI scanning in characterizing these lesions were 30%, 70% and 87%, respectively. There were no postoperative deaths and three postoperative complications that were successfully managed non-operatively. With a median follow-up of 24 months in the surgically treated group, one patient has developed recurrent symptoms of pain. CONCLUSION. In this series, there was no mortality directly due to the surgical procedure and a modest morbidity, justifying surgical resections in selected patients.

Outcomes after major hepatectomy in elderly patients.

BACKGROUND: We aimed to study the early and longterm outcomes of patients 70 years and older undergoing major liver resections, and compare the results with patients below the age of 70 years. STUDY DESIGN: All patients undergoing major liver resection (defined as three segments or more) from January 1993 to June 2004 were included. Patients were studied in two groups: 70 years of age and older (group E, elderly) and less than 70 years old (group Y, young). Early outcomes and longterm survival were analyzed. RESULTS: A total of 517 patients underwent major liver resection: group E, n=127; group Y, n=390 patients. There was no difference in operative mortality (group E, 7.9%; group Y, 5.4%; p=0.32) or postoperative morbidity (p=0.22) between the groups. Overall and disease-free survivals were not notably different for all patients (59% versus 57%, p=0.89; 60% versus 55%, p=0.28, respectively) or for a subgroup of patients with colorectal liver metastases (61% versus 55%, p=0.76; 60% versus 47%, p=0.07) in groups E versus Y, respectively. In multivariable analysis, American Society of Anesthesiologists grade 3 (p=0.024, hazard ratio [HR]=1.59, versus grade 1, 95% CI=1.06 to 2.39) and intraoperative transfusion>3 U (p<0.0005, HR=2.56, 95% CI=1.84 to 3.56) were predictors for overall survival. More than three tumors (p=0.025, HR=1.41, 95% CI=1.04 to 1.90) and redo resection (p=0.001, HR=2.80, 95% CI=1.51 to 5.19) were predictors of disease-free survival. CONCLUSIONS: Major liver resections can be safely performed in patients 70 years of age or older, with early results and survival similar to those in the younger than 70 age group. American Society of Anesthesiologists grade 3 and intraoperative transfusions>3 U were predictors for overall survival, and more than three tumors and redo resection were predictors for disease-free survival.

Left hepatic trisectionectomy for hepatobiliary malignancy: results and an appraisal of its current role.

OBJECTIVE: To analyze results of 70 patients undergoing left hepatic trisectionectomy and to clarify its current role. SUMMARY BACKGROUND DATA: Left hepatic trisectionectomy remains a complicated hepatectomy, and few reports have described the long-term results of the procedure. METHODS: Short-term and long-term outcomes of 70 consecutive patients who underwent left hepatic trisectionectomy from January 1993 to February 2004 were analyzed. RESULTS: Of the 70 patients, 36 had colorectal liver metastasis, 24 had cholangiocarcinoma, 4 had hepatocellular carcinoma, and the remaining 6 had other tumors. Overall morbidity, 30-day and 90-day mortality rates were 46%, 7%, and 9%, respectively. Multivariate analysis disclosed that preoperative jaundice and intraoperative blood transfusion were positive independent predictors for postoperative morbidity; however, there were no independent predictors for postoperative mortality. Postoperative morbidity (87% versus 35%, P < 0.001) and mortality (20% versus 5%, P = 0.108) were observed more frequently in patients with preoperative obstructive jaundice than in those without jaundice. Each survival according to tumor type was acceptable compared with reported survivals. Survival for patients with colorectal liver metastasis undergoing left hepatic trisectionectomy with concomitant partial resection of the remnant liver was similar to those without this concomitant procedure. This concomitant procedure was not associated with postoperative morbidity and mortality. CONCLUSIONS: Left hepatic trisectionectomy remains a challenging procedure. Preoperative obstructive jaundice considerably increases perioperative risk. Concomitant partial resection of the remaining liver appears to be safe and offers the potential for cure in patients with colorectal metastasis affecting all liver segments.