Adjuvant chemotherapy is associated with better oncological outcomes after ALPPS for colorectal liver metastases.

ALPPS enables complete tumor resection in a shorter interval and a larger number of patients than classic two-stage hepatectomies. However, there is little evidence regarding long-term outcomes in patients with colorectal liver metastases (CLM). This study aims to evaluate the short and long-term outcomes of ALPPS in patients with CRM. Single-cohort, prospective, observational study. Patients with unresectable CLM due to insufficient liver remnant who underwent ALPPS between June 2011 and June 2021 were included. Of 32 patients treated, 21 were male (66%) and the median age was 56 years (range = 29-81). Both stages were completed in 30 patients (93.7%), with an R0 rate of 75% (24/32). Major morbidity was 37.5% and the mortality nil. Median overall survival (OS) and recurrence-free survival (RFS) were 28.1 and 8.8 months, respectively. The 1-3, and 5-year OS was 86%, 45%, and 21%, and RFS was 42%, 14%, and 14%, respectively. The only independent risk factor associated with poor RFS (5.7 vs 11.6 months; p = 0.038) and OS (15 vs 37 months; p = 0.009) was not receiving adjuvant chemotherapy. KRAS mutation was associated with worse OS from disease diagnosis (24.3 vs. 38.9 months; p = 0.025). ALPPS is associated with favorable oncological outcomes, comparable to traditional strategies to increase resectability in patients with CLM and high tumor burden. Our results suggest for the first time that adjuvant chemotherapy is independently associated with better short- and long-term outcomes after ALPPS. Selection of patients with KRAS mutations should be performed with caution, as this could affect oncological outcomes.

Assessing juvenile swordfish (Xiphias gladius) diet as an indicator of marine ecosystem changes in the northwestern Mediterranean Sea.

To preserve marine biodiversity, we need reliable early warning indicators that inform changes in marine ecosystems. As reliable samplers of mid-trophic level communities, studying the trophodynamics of large pelagic fish can contribute to monitoring these changes. Here, we combined stomach content and stable isotope analyses to reconstruct the diet of juvenile swordfish (Xiphias gladius) in the northwestern Mediterranean Sea, in a time-lapse of almost a decade (2012 and 2020). Overall, our study showed that swordfish fed on a wide range of fish and cephalopod species from both pelagic and demersal habitats. A dietary shift towards increasing consumption of cephalopods and decreasing consumption of Gadiformes had been observed between 2012 and 2020. Stable isotope approaches revealed that gelatinous organisms were also important prey, particularly for smaller-sized swordfish. We underline the importance of combining multiple and complementary approaches to better reconstruct the diet of generalist species. Our findings highlight the generalist and opportunistic diet of Mediterranean swordfish, which makes them good candidates for monitoring changes in the ecosystem.

Atlantic Oceanic Squids in the "Grey Speciation Zone".

Cryptic species complexes represent an important challenge for the adequate characterization of Earth's biodiversity. Oceanic organisms tend to have greater unrecognized cryptic biodiversity since the marine realm was often considered to lack hard barriers to genetic exchange. Here, we tested the effect of several Atlantic and Mediterranean oceanic barriers on 16 morphospecies of oceanic squids of the orders Oegopsida and Bathyteuthida using three mitochondrial and one nuclear molecular marker and five species delimitation methods. Number of species recognized within each morphospecies differed among different markers and analyses, but we found strong evidence of cryptic biodiversity in at least four of the studied species (Chtenopteryx sicula, Chtenopteryx canariensis, Ancistrocheirus lesueurii, and Galiteuthis armata). There were highly geographically structured units within Helicocranchia navossae that could either represent recently diverged species or population structure. Although the species studied here can be considered relatively passive with respect to oceanic currents, cryptic speciation patterns showed few signs of being related to oceanic currents. We hypothesize that the bathymetry of the egg masses and duration of the paralarval stage might influence the geographic distribution of oceanic squids. Because the results of different markers and different species delimitation methods are inconsistent and because molecular data encompassing broad geographic sampling areas for oceanic squids are scarce and finding morphological diagnostic characters for early life stages is difficult, it is challenging to assess the species boundaries for many of these species. Thus, we consider many to be in the "grey speciation zone." As many oceanic squids have cosmopolitan distributions, new studies combining genomic and morphological information from specimens collected worldwide are needed to correctly assess the actual oceanic squid biodiversity.

An extension of the characteristic curve model of plant species behavior in heavy metal soils.

This article proposes a mathematical model to characterize phytoremediation processes in soils contaminated with heavy metals. In particular, the proposed model constructs characteristic curves for the concentrations of several metals (As, Cd, Cu, Fe, Pb, Sb, and Zn) in soils and plants based on the experimental data retrieved from several bibliographical sources comprising 305 vegetal species. The proposed model is an extension of previous models of characteristic curves in phytoremediation processes developed by Lam et al. for root measurements using the bioconcentration factor. However, the proposed model extends this approach to consider roots, as well as aerial parts and shoots of the plant, while at the same time providing a less complex mathematical formula compared to the original. The final model shows an adjusted R2 of 0.712, and all its parameters are considered statistically significant. The model may be used to assess samples from a given plant species to identify its potential as an accumulator in the context of soil phytoremediation processes. Furthermore, a simplified version of the model was constructed using an approximation to provide an easy-to-compute alternative that is valid for concentrations below 37,000 mg/kg. This simplified model shows results similar to the original model for concentrations below this threshold and it uses an adjusted factor defined as [Formula: see text] that must be compared with a threshold depending on the metal, type of measurement, and target (e.g., accumulator or hyperaccumulator). The full model construction shows that 90 out of the 305 species assessed have a potential behavior as accumulators and 10 of them as hyperaccumulators. Finally, out of the 1405 experimental measurements, 1177 were shown to be accumulators or hyperaccumulators. In particular, 85% of the results coincide with the reported values, thus validating the proposed model.

Heavy metal pollution index calculation in geochemistry assessment: a case study on Playa Las Petroleras.

This work is aimed to assess potential risk associated with the presence of metals and metalloids in soil at "Playa Las Petroleras" sector, located in Antofagasta (Chile). The zone under study has been affected by four oil spill events. This sector is located in an urban area by the sea. So, it has a great social and environmental relevance. The concentrations of 15 elements in soil samples were assessed, four of them presenting potential ecological risk: As, Co, Cu, and Pb. Nine pollution indices were applied to data: four single pollution indices and five integrated pollution indices to assess soil pollution. The single pollution indices show that the site bears potential ecological and environmental risk due to the presence of Cu, the site being classified as highly contaminated owing to a severe enrichment of this metal. For Co, all the indices allow classifying the site as little or uncontaminated, while the level of As and Pb pollution could be considered as ranging from uncontaminated to moderately contaminated. The integrated pollution indices show that average concentrations are highly contaminated mainly owing to the presence of Cu.

Characteristic curve modeling of plant species behavior in soils with heavy metals.

Many vegetal species can accumulate great amounts of metallic elements in their tissues. For this reason, they are called metal hyperaccumulators. An indicator of great interest in environmental sciences is the bioconcentration factor because it is recognized for establishing the potential accumulation of chemicals in organisms. Particularly in soil phytoremediation processes, it measures the capacity of a certain plant to capture metals, in terms of soil concentration. According to their behavior, four types of plants can be distinguished regarding soil concentration increase: indicator, excluder, accumulator, and hyperaccumulator. This study proposes a new model to categorize plants according to their behavior related to soil concentration increase, using several characteristic curves obtained from 1288 experimental measurements collected from different bibliographic sources. The metals analyzed were Cu, Fe, Pb, and Zn. The proposed model is obtained through linear regression and nonlinear transformations to model the expected behavior of plants in high concentration conditions. In particular, the basic equation of the model has three key components to represent the expected concentration in the plant root given the final soil concentration level, the type of species, and specific metal: a linear factor that determines the growth for low concentration values, an exponential factor that determines its decrease for high concentration values, and a logarithmic factor that limits the maximum value that can be reached in practice and influences the decay for high concentration values. After fitting the experimental data using linear regression, the proposed model has a 0.084 R2 determination coefficient and all of its parameters are considered significant. Furthermore, it shows that 60 of the 257 species assessed behave as accumulators and 10 of them as hyperaccumulators. The main contribution of this model is its ability to handle soils with high concentrations, where it would be hard for plants to achieve concentrations similar to or higher than the substrate containing them. Thus, the conventional criterion of the bioconcentration factor would incorrectly categorize a plant as an excluder. In contrast, this new model allows assessing plant effectiveness in a phytoremediation process of highly concentrated affected sites, such as mine tailings.

Collecting and Culturing Lineus sanguineus to Study Nemertea WBR.

Whole-body regeneration, the ability to reconstruct complete individuals from small fragments, is rare among ribbon worms (phylum Nemertea) but present in the pilidiophoran species Lineus sanguineus. This species can regenerate complete individuals from a tiny midbody section, and even from a quarter of a piece, provided it retains a fragment of a lateral nerve cord. While a few other unrelated species of ribbon worms are also excellent regenerators, L. sanguineus is unique in having evolved its regenerative abilities quite recently and thus offers an exceptional opportunity to gain insight into the evolutionary mechanisms of regeneration enhancement. Interestingly, both its sister species Lineus lacteus and Lineus pseudolacteus, a third species derived from the recent hybridization of the other two, differ in their regeneration abilities: while L. lacteus is uncapable of regenerating a lost head, L. pseudolacteus is capable of anterior regeneration, albeit at a slower rate than L. sanguineus. L. sanguineus has a worldwide distribution in temperate shores of both hemispheres, is readily found at intertidal habitats, and can survive, feed and be bred through asexual replication with minimal effort in laboratory settings. All the above make this species a superb candidate for studies of regenerative biology. In this chapter, we present protocols to collect, identify and breed L. sanguineus to study the extraordinary whole-body regeneration abilities found in this species.

Phylogenomics illuminates the evolution of bobtail and bottletail squid (order Sepiolida).

Bobtail and bottletail squid are small cephalopods with striking anti-predatory defensive mechanisms, bioluminescence, and complex morphology; that inhabit nektobenthic and pelagic environments around the world's oceans. Yet, the evolution and diversification of these animals remain unclear. Here, we used shallow genome sequencing of thirty-two bobtail and bottletail squids to estimate their evolutionary relationships and divergence time. Our phylogenetic analyses show that each of Sepiadariidae, Sepiolidae, and the three subfamilies of the Sepiolidae are monophyletic. We found that the ancestor of the Sepiolinae very likely possessed a bilobed light organ with bacteriogenic luminescence. Sepiolinae forms a sister group to Rossinae and Heteroteuthinae, and split into Indo-Pacific and Atlantic-Mediterranean lineages. The origin of these lineages coincides with the end of the Tethys Sea and the separation of these regions during the Eocene and the beginning of the Oligocene. We demonstrated that sepiolids radiated after the Late Cretaceous and that major biogeographic events might have shaped their distribution and speciation.

Neutrophil-to-lymphocyte ratio vs C-reactive protein as early predictors of anastomotic leakage after colorectal surgery: A retrospective cohort study.

INTRODUCTION: Colorectal surgery (CRS) is associated with high morbidity rates, being anastomotic leakage (AL) one of the most serious complications with an incidence as high as 15%, accounting for up to a third of mortality in these procedures. The identification of pre-clinical markers may allow an early diagnosis and a timely intervention. The objective of the present study was to compare the performance of neutrophil-to-lymphocyte ratio (NLR) vs C-reactive protein (CRP) as early predictors of AL in CRS. METHODS: A retrospectively analyzed consecutive patients who underwent a colorectal surgery with anastomosis from June 2015 to April 2019. Receiver-operating characteristic (ROC) curves were used to find the cutoff points with the best diagnostic performance of AL. RESULTS: A total of 116 patients were included. From 43 patients (37%) who developed a total of 63 complications, 9 (7.76%) presented with an AL with a median of 8 days (range: 5-9). No significant differences were found for NLR between patients with vs without AL. In contrast, median CRP was significantly higher in patients who subsequently presented with AL, both on day 4 (164 vs 64, p = 0.04) and 5 (94 vs 44, p < 0.001) after surgery. The best predictive performance through ROC curves was found on postoperative day 5, with a CRP value of >54 mg/dL (AUC: 0.81, Sensitivity: 89%, Specificity: 61%). CONCLUSIONS: CRP appears superior to NLR as an early predictor of AL following CRS. The best diagnostic performance was obtained on postoperative day 5 with a cutoff value of >54 mg/dL.

Neutrophil-to-lymphocyte ratio as a predictor of complicated acute diverticulitis: A retrospective cohort study.

INTRODUCTION: Currently, the debate on the usefulness of Neutrophil to Lymphocyte Ratio (NLR) as a predictor of complications in acute diverticulitis (AD) remains open, especially, the relation to the severity of the disease, the clinical impact, and the necessity of minimally invasive or emergency surgical procedures. On the other hand, its diagnostic efficacy has not been studied even in our field. The objective of the present study was to determine the utility and diagnostic precision of NLR in complicated acute diverticulitis (cAD). METHODS: Descriptive, retrospective cohort and analytical study. Patients older than 18 years with a diagnosis of AD were included, from 2013 to 2018. Demographic variables, days of hospitalization, leukocyte count, neutrophils, lymphocytes, ESR, CRP, and NLR were analyzed. The sensitivity and specificity for the diagnosis of cAD were determined using ROC curves. RESULTS: 325 patients were included. Of these 196 (60%) were men. The median age was 52 years. A total of 30 (9%) were categorized as cAD. The patients with cAD presented mean values in the leukocyte count (14.02 ± 4.49 × 109/l; p < 0.01), CRP (119.60 ± 87.67; p < 0.01) and NLR (7.61 ± 4.03; p < 0.01). An NLR cutoff value ≥ 4.2 was identified as the most appropriate to distinguish cAD, with a sensitivity of 80%, a specificity of 64%, NPV of 96%, and PPV of 18%. CONCLUSION: NLR is a predictive marker of cAD, with a cut-off point of 4.2 being the best diagnostic approach.

Minimally invasive splenectomy in grade IV splenic trauma: A case report associated with high-grade renal trauma.

INTRODUCTION AND IMPORTANCE: In closed abdominal trauma, the spleen is the most frequently injured organ (30-45%). Splenic lesions grades IV-V have higher failure rates with nonoperative management (NOM). The minimally invasive approach is an alternative when NOM fails. This is the first reported case of a patient with splenic and left renal trauma, both grade IV, with combined management, which consisted of a minimally invasive surgical resolution of the splenic trauma and a conservative management of the renal trauma, with a satisfactory recovery of the patient. This contributes to understanding the benefits of minimally invasive surgery in moderate splenic trauma associated with other high-grade injuries. CASE PRESENTATION: We present a 45-year-old woman with a multiple trauma after a motorbike vs car traffic accident. On physical examination, she was hemodynamically stable, with abdominal guarding and generalized rebound tenderness associated with multiple upper and lower limb fractures. An abdominal CT scan revealed grade IV splenic and left renal trauma, with moderate hemoperitoneum. A minimally invasive laparoscopic approach for hemoperitoneum drainage and splenectomy was performed. CLINICAL DISCUSSION: There is currently no consensus to define the indications for minimally invasive treatment on splenic trauma. While laparotomy is the standard treatment, it is not without potential severe complications, while laparoscopy providing a treatment option in selected cases with hemodynamic stability. CONCLUSION: The role of the minimally invasive approach is safe and feasible in selected patients with high-grade splenic lesions and hemodynamic stability, including the association with other organic lesions such as kidney trauma.

Titanium clip migration after cholecystectomy: original technique for laparoscopic transcystic extraction when endoscopic retrograde cholangiopancreatography fails.

Surgical clip migration into the common bile duct (CBD) is a rare complication after laparoscopic cholecystectomy (LC). Few cases of surgical clip migration have been reported in the literature, and most of them have been successfully treated with endoscopic retrograde cholangiopancreatography (ERCP). We present a 71-year-old woman with 48 h of abdominal pain, jaundice and fever 6 years after laparoscopic cholecystectomy. She was diagnosed with common bile duct obstruction from surgical clip migration. After failure of ERCP, the patient was successfully treated with an innovative approach by laparoscopic transcystic extraction using endoscopic hose-type biopsy forceps. The presented technique was feasible and safe in expert hands, representing a valuable alternative to avoid the need of a choledochotomy in patients with unsuccessful ERCP.

Methodology to Prioritize Chilean Tailings Selection, According to Their Potential Risks.

For centuries, Chile has been a territory with significant mining activity, resulting in associated social benefits and impacts. One of the main challenges the country faces today is the presence of a great number of mine tailings containing heavy metals, such as Cu, Cr, Ni, Zn, Pb, As, Cd, and Fe, which make up a potential risk for the population. This study is intended to develop a methodology for determining tailings requiring urgent treatment in Chile, based on risks associated with heavy metals. Geochemical data from 530 Chilean tailings were compared to the Dutch norm and the Canadian and Australian soil quality guidelines for residential use. Additionally, criteria about residents and water bodies were used, considering a 2-km area of influence around tailings. To do this, QGIS (Böschacherstrasse 10a CH-8624 Grüt (Gossau ZH),Zurich, Switzerland), a geospatial tool, was used to geolocate each deposit, considering regions, communes, rivers, lakes, and populated areas. To evaluate potential ecological contamination risks, Hakanson's methodology was used. Results revealed the presence of 12 critical tailings in Chile that require urgent treatment. From the 530 tailings evaluated, 195 are located at less than 2 km from a populated area and 154 at less than 2 km from a water body. In addition, 347 deposits require intervention: 30 on Cu, 30 on Cr, 13 on Zn, 69 on Pb, 138 on As, 1 on Cd, and 5 on Hg.

Fellows perspective of HPB training in Latin America.

BACKGROUND: Currently, no standards for HPB training exist in Latin America. The aim of this work is to evaluate fellows' experience of HPB training and the areas of opportunity to improve. METHODS: A 35 points survey was developed and distributed among fellows from dedicated HPB training programs in Latin America. The survey was applied by direct phone call (37%) or web based (63%), to fellows graduated between 2010 and 2014, from 7 different programs. RESULTS: Thirty-nine fellows from Argentina, Brazil, Chile and México were considered with a response rate of 82% (32/39). Most fellows (90%) shared cases with more than one co-fellow. Scrubbing with chief residents ocurred to 60% of fellows; only 14% of fellows noted having a primary surgeon role in more than 70% of cases. Median number of major hepatectomies during training was 15 (1-100), Whipple procedures 6 (1-40), and major bile duct repair 20 (1-80). Limited funding was the main reason to avoid HPB programs outside the country of origin. CONCLUSION: HPB training in Latin America requires more operative volume and autonomy. Financial burden is the main limitation to pursue training overseas. A multinational fellowship that takes advantage of each center may overcome differences in volume and type of cases.

Hemicolectomía derecha laparoscópica con abordaje suprapúbico: una técnica novedosa para el tratamiento del cáncer de colon / Suprapubic laparoscopic right hemicolectomy: a novel technique for the treatment of colon cancer

Antecedentes: la hemicolectomía derecha laparoscópica con abordaje suprapúbico (HDLS) y empleo de tecnología robótica o laparoscópica de incisión única ha sido recientemente informada. La utilización de la técnica estándar multipuerto en HDLS no se ha descripto previamente. Material y métodos: entre enero y agosto del año 2018 fueron intervenidos 4 pacientes, 3 mujeres y 1 hombre, con mediana de 64 años de edad y diagnóstico de adenocarcinoma de colon derecho. Resultados: el procedimiento se realizó exitosamente en todos los pacientes, con una mediana de tiempo operatorio de 210 minutos (r:170-240). Ningún paciente tuvo complicaciones y fueron dados de alta en una mediana de 4 días (r:3-5). Todas las piezas quirúrgicas tuvieron márgenes negativos y un recuento ganglionar > 12 ganglios. A 7, 5, 4 y 2 meses del seguimiento, los pacientes se hallan vivos y libres de enfermedad. Conclusión: la técnica de HDLS multipuerto es una alternativa sencilla, factible y segura para el tratamiento del cáncer de colon en pacientes seleccionados, con un resultado funcional, estético y oncológico favorable.

Background: The suprapubic approach for laparoscopic right hemicolectomy has been reported with robotic surgery or single incision laparoscopy. The use of the suprapubic approach for standard multiport laparoscopic right hemicolectomy has not been previously described. Material and methods: Between January and September 2018, four consecutive patients (three women and one man; median age: 64 years) with right-sided colon cancer underwent laparoscopic right hemicolectomy using the suprapubic multiport approach. Results: The procedure was successful in all the patients and mean operative time was 210 minutes (IQR: 170-240). There were no complications and were discharged on postoperative day 4 (IQR: 3-5). All the surgical specimens had negative margins and lymph node count was > 12 lymph nodes. All the patients are alive and free from disease at 7, 5, 4 and 2 months of follow-up. Conclusion: The suprapubic approach for standard multiport laparoscopic right hemicolectomy is an easy, feasible and safe alternative for the treatment of colon cancer in selected patients, with a favorable functional, esthetic and oncological result.

Laparoscopic Distal Pancreatectomy With Peritoneal Staple-line Reinforcement: A Novel Technique (With Video).

INTRODUCTION: Postoperative pancreatic fistula (PPF) is still the major source of morbidity in distal pancreatectomy (DP). Despite the many surgical techniques and technology devices developed for the closure of the pancreatic stump, the PPF rate remains high, and there is no consensus with regard to the most appropriate stump closure technique. We herein present, for the first time, an innovative approach for staple-line reinforcement in DP using an autologous peritoneal patch. MATERIALS AND METHODS: The results of 2 consecutive patients who underwent laparoscopic DP due to mucinous cystic neoplasms were included in this report. The pancreas was transected with a reinforced stapler using a peritoneal patch obtained from the anterolateral wall of the abdomen, divided into 2 pieces, and sutured around each stapler jaw. The embedded video (Supplemental Digital Content 1, http://links.lww.com/SLE/A209) reports our standardized technique. RESULTS: Both patients had a favorable recovery without PPF or any complication and were discharged fully recovered 4 and 5 days after surgery without drains. Currently, both patients are alive and free of disease 1 year and 8 months after the procedure. CONCLUSIONS: The use of an autologous parietal peritoneal patch for staple-line reinforcement in DP was feasible and safe in experienced hands. Further studies are needed to confirm our findings and elucidate whether this readily available, inexpensive, rapid, and versatile alternative could reduce the PPF rate.

A phylum-wide survey reveals multiple independent gains of head regeneration in Nemertea.

Animals vary widely in their ability to regenerate, suggesting that regenerative ability has a rich evolutionary history. However, our understanding of this history remains limited because regenerative ability has only been evaluated in a tiny fraction of species. Available comparative regeneration studies have identified losses of regenerative ability, yet clear documentation of gains is lacking. We assessed ability to regenerate heads and tails either through our own experiments or from literature reports for 35 species of Nemertea spanning the diversity of the phylum, including representatives of 10 families and all three orders. We generated a phylogenetic framework using sequence data to reconstruct the evolutionary history of head and tail regenerative ability across the phylum and found that all evaluated species can remake a posterior end but surprisingly few could regenerate a complete head. Our analysis reconstructs a nemertean ancestor unable to regenerate a head and indicates independent gains of head regenerative ability in at least four separate lineages, with one of these gains taking place as recently as the last 10-15 Myr. Our study highlights nemerteans as a valuable group for studying evolution of regeneration and identifying mechanisms associated with repeated gains of regenerative ability.

Indocyanine green fluorescence imaging to evaluate graft perfusion during liver transplantation.

BACKGROUND: Primary graft dysfunction (PGD) is a leading cause of graft loss after liver transplantation. There is no reliable method to anticipate this complication intraoperatively. Indocyanine green (ICG) fluorescence imaging is a technique used in hepatobiliary surgery for detection of liver malignancies, but has never been reported in the setting of liver transplantation (LT) for function assessment. We hypothesized that there could be an association between the type of fluorescence and the occurrence of PGD. METHODS: We retrospectively analyzed 72 patients who underwent LT at our center. An assessment of the liver graft with the ICG fluorescence technique was carried out. A classification comprising 3 types of fluorescence was created after evaluation of the recorded images. We assessed the relationship between the type of fluorescence and the occurrence of PGD. RESULTS: Crosstabulation analysis of the fluorescent types and occurrence of PGD yielded a statistically significant association (p = 0.002). Univariate analysis showed that an abnormal ICG fluorescence pattern was a risk factor for the occurrence of PGD after LT. CONCLUSIONS: Our findings suggest that there could be an association between ICG fluorescence imaging and graft function. This intraoperative tool could be useful to detect patients at risk of developing PGD after LT.

Multiple primary tumors: Colorectal carcinoma and non-Hodgkin's lymphoma.

INTRODUCTION: Colorectal cancer (CRC) is the third most commonly diagnosed cancer, whereas lymphoma is the sixth leading cause of cancer death, 90% of which corresponds to non-Hodgkin's lymphoma (NHL). The association of these two primary tumors, a solid tumor with an hematological malignancy, is very uncommon. PRESENTATION OF CASE: We report the case of a 47-year-old man who presented with abdominal pain, a right upper quadrant mass and 12 kg of weight loss in 9 months. The computed tomography (CT) showed a large intra-abdominal mass and a wall thickening at the rectosigmoid junction. A colonoscopic biopsy confirmed a colorectal adenocarcinoma and a laparoscopic biopsy of the intraabdominal mass confirmed a diffuse large B-cell NHL. After multidisciplinary discussion it was decided to treat first the NHL with 3 cycles of R-CHOP chemotherapy (cyclophosphamide, doxorubicin, vincristine and prednisone). The patient experienced a good response with a 70% decrease in the intraabdominal mass and a negative PET/CT. Four months after diagnosis an anterior rectal resection was performed. The patient recovered uneventfully and was discharged 5 days after surgery. The patient finally died 20 months after surgery due to disease progression. DISCUSSION: The association of CRC and NHL is an extremely rare scenario that represents a great multidisciplinary challenge with respect to treatment due to the scarce literature found on this topic. CONCLUSION: When CRC and NHL are present, all the different disease patterns must be considered in a multidisciplinary and patient-oriented fashion, in order to decide the best therapeutic strategy for each individual.

Totally Laparoscopic Mini-ALPPS Using a Novel Approach of Laparoscopic-Assisted Transmesenteric Portal Vein Embolization.

BACKGROUND: The initial mortality rates of associating liver partition and portal vein occlusion for staged hepatectomy (ALPPS) were high. However, recent data from the International Registry show a continuous reduction of early mortality and major morbidity due to risk adjustment in patient selection and less invasive techniques in stage-1 surgery. During the first ALPPS International Consensus in 2015, we introduced a paradigm inversion of ALPPS, the so-called "Mini-ALPPS." METHODS: We combined a partial liver partition with a novel technique of laparoscopic-assisted percutaneous cannulation of the inferior mesenteric vein for intraoperative transmesenteric portal vein embolization. We report here for the first time, a case of a successful totally laparoscopic Mini-ALPPS, and describe in detail the technical aspects of this new approach. RESULTS: A 61-year-old man with a 6 cm hepatocellular carcinoma compromising the right glissonian pedicle in a fibrotic liver was treated by an extended right hepatectomy using the laparoscopic Mini-ALPPS approach. The patient had an uneventful first stage and was discharged 3 days after. A CT scan performed on postoperative day 8 showed sufficient future liver remnant volume after a 59% hypertrophy. An extended right hepatectomy was uneventfully completed and the patient was discharged 5 days after surgery. The histopathological analysis indicated advanced F4 liver fibrosis and negative tumor margins. CONCLUSIONS: This technical innovation allows avoiding a laparotomy to access the mesenteric venous territory and the risks of liver remnant injuries during percutaneous transhepatic approach. This new alternative may result of great utility not only in ALPPS but also for many different circumstances and scenarios.