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Perihilar cholangiocarcinoma or Klatskin tumors are a rare entity arising from the extrahepatic bile duct bifurcation. Considering the close anatomical relationship of the bile duct bifurcation with the portal vein bifurcation and hepatic arteries, surgical treatment is demanding. With an incidence of only 2-4 cases/100,000 population/year patients should be referred to a specialized center. The tumors are usually poorly differentiated adenocarcinomas growing diffusely along the duct and also the perineural sheath. Only radical surgery offers a curative option and currently surgical strategy usually consists of en bloc resection of the bile duct, extended liver resection and portal vein resection. Proximal and lateral safety margin R0 resections are technically very demanding procedures because of the local anatomy. [ABSTRACT FROM AUTHOR]

Introduction: Pylorus-preserving partial pancreatoduodenectomy is a complex visceral operation, especially when simultaneous resection and reconstruction of the portal venous axis is necessary. Pancreatic anastomosis plays a decisive role in this procedure, since postoperative pancreatic fistula (POPF) is a frequent complication, with serious consequences (morbidity and mortality) for the affected patient. Various techniques are available for anastomosing the residual pancreas: the duct-to-mucosa pancreaticojejunostomy, invaginating pancreatojejunostomy, Blumgart anastomosis and pancreatogastrostomy., Indication: Adenocarcinoma of the pancreatic head with portal vein infiltration., Procedure: Pylorus-preserving pancreaticoduodenectomy (PPPD) with portal vein resection., Conclusion: A standardised and structured approach to pylorus-preserving partial pancreatoduodenectomy helps the surgeon to perform this procedure safely. Performing a simultaneous portal vein resection increases the complexity of the procedure, but nonetheless, if infiltration of the portal venous axis is suspected, the indication for en-bloc resection should be given generously, as intraoperatively it is not possible to differentiate reliably between inflammatory adherence and tumour infiltration and portal vein/V.-mesenterica-superior-resection does not increase morbidity and mortality. The choice of the surgical technique for anastomosing the residual pancreas should be made by the surgeon on the basis of his expertise and, if necessary, adapted to the patient's situs, since the most important pancreatic anastomosis techniques appear to be equivalent according to the current evidence., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Extended left hemihepatectomy (left trisectionectomy) with resection of liver segments 1, 2, 3, 4 a/b, 5 and 8 is a challenging procedure. In well-selected patients, the indication for this procedure may offer the chance of curative resection for primary or secondary liver tumours in complicated locations. Morbidity and mortality are increased compared to non-extended liver resections. This procedure requires precise imaging and accurate surgical planning in due consideration of the remaining liver volume and additional factors such as preliminary damage of the liver parenchyma caused by chemotherapy or fibrosis/cirrhosis. Left trisectionectomy is necessary in tumours affecting either the middle and left hepatic vein or the blood vessels of the liver hilum to the left and middle liver sector. The procedure necessitates the preservation of the right hepatic vein and the portal-venous and arterial branches supplying segments 6 and 7, as well as the bile ducts of these segments. This video article illustrates the surgical procedure of extended left hemihepatectomy performed due to an intrahepatic cholangiocellular carcinoma, which centrally surrounds the left and middle hepatic vein and potentially infiltrates the right hepatic vein. This condition requires the tangential resection and reconstruction of the right hepatic vein., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Retrospective analyses have shown a 20-40 % incidence of R1 resection in hilar cholangiocarcinoma, which therefore represents a significant issue to be addressed., Methods: We have reviewed the literature on the impact of R1 resection in hilar cholangiocarcinomas and on possible surgical options to increase the rate of complete tumour resections., Results: To minimise the rate of R1 resections a preoperative risk assessment concerning the predisposed anatomic locations is required. During planning of the surgical strategy, liver function plays a central role prior to right-sided hemihepatectomies. Due to the loss of a high amount of functional liver parenchyma, contralateral portal vein embolisation is often used prior to right trisectionectomies. For left-sided hepatectomies the management of the right hepatic artery is fundamental. The right hepatic artery has a very close contact to the tumour region, although arterial invasion is rarely seen. However, the risk of manifest or occult R1 resection is relatively high along the right artery. In selected cases an arterial resection might be considered, but this increases the risk of postoperative complications. Arterial resection might be performed either via direct anastomosis or by using an interposition graft. As reserve procedures preoperative embolisation of the hepatic artery without reconstruction or an arterialisation of the portal vein are available. However, the latter two procedures come along with an increased rate of biliary complications. In selected lymph-node negative patients with irresectable hilar cholangiocarcinoma liver transplantation might be considered., Conclusion: Despite significant advances in surgical technique, R1 resection remains a problem, which is aggravated by the lack of evidence-based adjuvant measures., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Due to their size or location liver tumors can infiltrate important vascular structures, which are essential for postoperative liver function., Objective: To present the technical possibilities and results of current concepts of vascular resection and reconstruction in liver surgery., Material and Methods: A literature search of the Medline and Cochrane databases was performed regarding currently available studies on vascular resection and reconstruction in liver surgery., Results: Portal vein resections are routinely performed by many institutions and can be performed as an end-to-end anastomosis or graft interposition. This is the basis of the en bloc resection concept, especially for Klatskin tumors. Reconstruction of the inferior vena cava as well as the hepatic arteries is technically feasible and is increasingly being reported in smaller series. In particular, the resection of tumors near the hepatic veins may require total vascular exclusion for complete interruption of liver perfusion, which enables resection in the non-perfused liver and by this reduced blood loss. Furthermore, in situ cooling, ante situm and ex situ resections increase both technical resectability and the ischemic tolerance of the liver to more than 60 min. The majority of vascular reconstructions can be performed without a significant increase in morbidity; however, vascular tumor infiltration is associated with impaired long-term survival., Conclusion: Based on the experience of transplantation surgery concepts for vascular reconstruction can be safely applied to liver surgery. These concepts contribute to increasing the resectability of liver tumors. Due to the often impaired prognosis of vascular tumor infiltration, the use of these concepts should be individually assessed by weighing the prognosis against the morbidity.

The surgical treatment of hepatopancreatobiliary (HPB) diseases requires complex operative procedures. Within the last decades the morbidity (36-50 %) and mortality (<5 %) of these procedures could be reduced; nonetheless, postoperative complications still occur in 41.2 % of cases. Compared with hepatobiliary procedures, pancreatic surgery shows an increased rate of complications. Postoperative bleeding has a major effect on the outcome and the incidence is 6.7 % after pancreatic surgery and 3.2 % after hepatobiliary surgery. The major causes of early postoperative hemorrhage are related to technical difficulties in surgery whereas late onset postoperative hemorrhage is linked to anastomosis insufficiency, formation of fistulae or abscesses due to vascular arrosion or formation of pseudoaneurysms. In many cases, delayed hemorrhage is preceded by a self-limiting sentinel bleeding. The treatment is dependent on the point in time, location and severity of the hemorrhage. The majority of early postoperative hemorrhages require surgical treatment. Late onset hemorrhage in hemodynamically stable patients is preferably treated by radiological interventions. After interventional hemostatic therapy 8.2 % of patients require secondary procedures. In the case of hemodynamic instability or development of sepsis, a relaparotomy is necessary. The treatment concept includes surgical or interventional remediation of the underlying cause of the hemorrhage. Other causes of postoperative morbidity and mortality are arterial and portal venous stenosis and thrombosis. Following liver resection, thrombosis of the portal vein occurs in 8.5-9.1 % and in 11.6 % following pancreatic resection with vascular involvement. Interventional surgical procedures or conservative treatment are suitable therapeutic options depending on the time of diagnosis and clinical symptoms. The risk of morbidity and mortality after HPB surgery can be reduced only in close interdisciplinary cooperation, which is particularly true for vascular complications.

Introduction: Patients with locally advanced pancreatic cancer and arterial infiltration of the coeliac artery are often classified as irresectable and therefore treated palliatively. For a highly selected group of patients, a complete resection (R0) of a pancreatic carcinoma including resection of the coeliac trunk without arterial reconstruction can mean a survival advantage. The expertise of the surgeon in vascular and pancreatic surgery as well as the proficiency of the entire surgical and anaesthesiological team and the appropriate infrastructure of the hospital are prerequisites for the success of such complex operations. Concerning the local finding of infiltration of the aorta, the gastroduodenal artery and the mesenteric superior artery should be excluded, to ensure R0 resection and perfusion of the liver via the gastroduodenal artery after resection. Moreover, the patient has to be fit for a large abdominal operation and extrapancreatic metastases have to be excluded, especially in ductal adenocarcinoma of the pancreas. In this video, the principles of the Appleby operation are shown in a case of locally advanced neuroendocrine carcinoma of the pancreas with infiltration of the coeliac artery., Indication: Locally advanced pancreatic neuroendocrine carcinoma with infiltration of the coeliac artery without distant metastasis after neoadjuvant therapy., Procedure: Extended multiorgan pancreatic corpus and tail resection including resection of coeliac artery, portal vein resection, splenectomy, resection of left adrenal gland, subtotal gastrectomy and oversewing of the pancreatic head, end-to-end reconstruction of the portal vein and gastro-jejunostomy (Roux-Y) and duodeno-jejunostomy., Conclusion: Given the appropriate experience, the Appleby procedure is a technically demanding resection in pancreatic carcinomas involving the coeliac artery without arterial anastomosis. In selected cases this operation might have advantages compared to palliative treatment., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: For a highly selected group of patients, a complete resection (R0) of a pancreatic carcinoma including arterial resection and reconstruction can represent an advantage in survival. The expertise of the surgeon in vascular and pancreatic surgery as well as the proficiency of the entire surgical and anaesthesiological team and the appropriate infrastructure of the hospital are prerequisites for the success of such complex operations. Proximal and distal of the tumour, sufficient lengths of the vessels are needed for the vascular anastomoses. In this video, the principles of arterial resection and reconstruction are shown in two patients with advanced pancreatic carcinoma., Indication: This procedure is indicated for locally advanced pancreatic carcinoma with arterial infiltration without distant metastasis after neoadjuvant therapy., Procedure: The procedure involves 2 steps: 1. pancreatic head resection with resection of the common hepatic artery and end-to-end anastomosis of the hepatic artery and portal vein resection; 2. left pancreatic resection including splenectomy; resection of the celiac trunk, the superior mesenteric artery; reinsertion of the superior mesenteric artery into the aorta; end-to-end anastomosis of the common hepatic artery with the stump of the celiac trunk., Conclusion: Given the appropriate experience, technically demanding arterial resections and reconstructions in pancreatic carcinoma are feasible and can provide superior survival for the patient compared to palliative therapy., (Georg Thieme Verlag KG Stuttgart · New York.)

The combination of right portal vein ligation with complete parenchyma dissection ("in-situ split", ISS) for rapid hypertrophy induction of the left-lateral liver lobe is a novel strategy to convert primarily irresectable liver tumours into a resectable stage. Available data so far show a 60-80 % growth induction of the remnant liver within 7(- 9) days. Certainly, a novel concept that comprises two operations within a very short time period raises questions. Based on the very few literature reports that have been published so far, as well as our own experience, we here discuss technical issues such as the use of a plastic sheet on the resection margin, the possibility of laparoscopic dissection and the timing of the second operation. Moreover, aspects of the preoperative diagnostic work-up that is necessary are assessed. Finally, open questions, e.g., concerning the influence of preoperative chemotherapy and the use of ISS in patients with cirrhosis are evaluated. In summary, the assessment of chances and risks of this novel concept with regard to indication and technical issues helps to provide the potentially curative option of the "in-situ split" procedure to more patients with marginal or even irresectable liver tumours., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: This study compared the technical aspects and results for two different techniques of total laparoscopic anatomical right hemihepatectomy., Patients and Methods: From September 2010 to February 2013 a total of 16 patients underwent total laparoscopic right hemihepatectomy at the University Hospital of Freiburg. Of the patients 8 received an intraglissonian approach (IGA) and the other 8 patients an extraglissonian approach (EGA). In the patients of the IGA group, vascular inflow control of the right liver was accomplished by dissection and dividing the right hepatic artery, the right portal vein and the right bile duct separately before parenchymal dissection. In contrast, vascular control for patients in the EGA group was performed by enclosure and transsection of the whole right pedicle using a vascular linear stapler., Results: Indications for right hemihepatectomy were benign tumors in 2 and malignancies in 14 cases. The average maximum tumor diameter was 5.5 cm (range 1.5-10.0 cm). Adequate tumor-free surgical margins (R0) were confirmed in all patients with malignancies. The perioperative mortality rate was 0 %, surgical complications according to Clavien's classification were grade I (n = 1 trocar site superficial wound infection), grade II (n = 2 cholangitis) and grade IIIb (n = 1 wound dehiscence after conversion to open procedure). The median operating time was 366 min (range 265-422 min) and 313 min (range 247-417 min) in the IGA and EGA groups, respectively. Conversion from laparoscopic to open minimal access procedure was necessary in three patients in the IGA group and two patients in the EGA group. Mean intraoperative blood loss was 644 ml (200-1000 ml) and 518 ml (200-1500 ml) in the IGA and EGA groups, respectively. Transfusion of two units of packed red blood cells was necessary for one patient in group EGA. No patient in either group needed a Pringle maneuver. Mean postoperative hospital stay was 11 days (range 7-23 days) and 13 days (range 7-31 days) in the IGA and EGA groups, respectively., Conclusions: Total laparoscopic anatomical right hemihepatectomy is a feasible procedure. The extraglissonian technique can provide shorter operating times by correctly facilitating vascular control of the right liver.

Perihilar cholangiocarcinoma or Klatskin tumors are a rare entity arising from the extrahepatic bile duct bifurcation. Considering the close anatomical relationship of the bile duct bifurcation with the portal vein bifurcation and hepatic arteries, surgical treatment is demanding. With an incidence of only 2-4 cases/100,000 population/year patients should be referred to a specialized center. The tumors are usually poorly differentiated adenocarcinomas growing diffusely along the duct and also the perineural sheath. Only radical surgery offers a curative option and currently surgical strategy usually consists of en bloc resection of the bile duct, extended liver resection and portal vein resection. Proximal and lateral safety margin R0 resections are technically very demanding procedures because of the local anatomy.

Early portal vein thrombosis is a frequent and severe complication following pediatric liver transplantation. The clinical presentation is characterized by signs and symptoms of portal hypertension such as ascites and digestive hemorrhage. Primary treatment consists of heparin therapy. In the case of persistent or progressive thrombosis or symptoms, surgical thrombectomy or retransplantation should be considered. However, surgical intervention is associated with significant morbidity and mortality. We report on successful minimally invasive percutaneous thrombus aspiration and thrombolysis for the treatment of acute portal vein thrombosis in a 5-year-old child post liver transplantation., (© Georg Thieme Verlag KG Stuttgart · New York.)

The considerable increase of the aged population in western civilisation within the next years will result in a rising incidence of pancreatic cancer. Until the year 2020 an increment of 20  % of patients beyond 65 years old can be anticipated. Therefore, the focus will be on management of old and geriatric surgical patients leading to strategical re-evaluation of surgical indications under critical consideration of feasibility and purpose. Even under modern interdisciplinary therapy concepts the prognosis of ductal adenocarcinoma of the pancreas remains poor with an overall 5-year survival rate of less than 5  %. The surgical resection is still considered as the only potential curative treatment option with extended life expectancy; however, it is technically demanding and furthermore associated with significant morbidity. In particular, the quality of surgery of the now interdisciplinary therapy of pancreatic cancer is markedly improved when performed at a high-volume centres. Until now only a few retrospective data analyses evaluating the perioperative and long-term outcome after pancreatic tumor resections in geriatric patients exist. The available results, however, support radical surgical procedures even beyond the age of 75 years.

Curative treatment of Klatskin tumors by radical surgical procedures with surgical preparation distant to the tumor region results in 5-year survival rates of 30-50%. This requires mandatory en bloc liver resection and resection of the extrahepatic bile duct often together with vascular resection. Nevertheless, the ideal safety margin of 0.5-1 cm remote from the macroscopic tumor extensions cannot be achieved in all cases. Based on hilar anatomy the probability of an adequate safety margin is higher using extended right hemihepatectomy together with portal vein resection compared to left hemihepatectomy. However, due to severe atrophy of the left liver lobe solely left-sided hepatectomy is feasible in some patients. In cases of eligibility for both procedures right hemihepatectomy is preferentially used due to the higher oncological radicality if sufficient liver function is present. Postoperative hepatic insufficiency and bile leakage after demanding biliary reconstruction, often with several small orifices, contribute to the postoperative complication rate of this complex surgical disease pattern.

Portosystemic shunt surgery in addition to transjugular intrahepatic portosystemic shunt (TIPS) insertion must still be regarded as a current treatment option for portomesenteric decompression in patients with pharmacological and endoscopic treatment failure, where liver transplantation is not imminent. This applies to secondary prophylaxis of rebleeding from varices in patients with well preserved liver function, e.g. liver cirrhosis CHILD A or extrahepatic portal vein thrombosis. Even if emergency endoscopy represents the treatment of choice in the acute bleeding situation, latest data from San Diego on emergency portacaval shunt surgery are encouraging. Likewise, portacaval shunt procedures can be an attractive alternative to TIPS or liver transplantation for acute Budd-Chiari syndrome or veno-occlusive disease.This article is an update on the systematics and methodology of portacaval shunt surgery, emphasizing the significance of this treatment option based on latest studies.

Purpose: To evaluate the feasibility of TIPS for portal vein thrombosis (PVT) with/without portal vein occlusion/cavernomatous transformation and with/without underlying cirrhosis., Materials and Methods: 13 patients with PVT and refractory ascites (n=7) and variceal bleeding (n = 6) received TIPS placement. The function of the TIPS was controlled with Doppler US at 1 day, 1 week, 4 weeks and 4 months after TIPS placement and subsequently every 3 months. The rates of technical success, revision and mortality after TIPS were evaluated., Results: The TIPS was successfully placed in 85% (11/13) of the cases. TIPS placement was successful in 87.5% (7/8) of patients with occlusion of the right portal vein and in 100% (5/5) of patients with non-occlusive right portal vein (p > 0.05), in 80% (8/10) of cirrhotic (x/10) and in 100% (3/3) of non-cirrhotic patients (p > 0,05), as well as in one patient with a fresh PVT and in 1 of 2 patients with cavernous transformation. 30 and 14.3% of patients needed a TIPS revision in the first and second year, respectively. No patient with occlusion of the right portal vein required a revision. 54.5% (6/11) of patients died within 6 months. Under exclusion of 4 patients with advanced malignant diseases, the mortality rate was 28.6%., Conclusion: TIPS should be considered for selected patients with symptomatic occlusive PVT with/without cavernous transformation and with/without underlying cirrhosis. The frequency of TIPS revision is not greater, and the mortality rate 6 months after PVT recanalization seems to be comparable with that of patients without PVT.

The Abernethy malformation is a rare congenital portosystemic shunt in which the blood directly drains into the systemic vein bypassing the liver either through a complete (type 1) or a partial shunt (type 2). The diagnosis is most frequently established primarily with ultrasound. CT and MRI are used for further classification of the shunt and assessment of accompanying liver tumors and malformations. There is a wide spectrum of therapeutic options ranging from noninvasive conservative treatment to liver transplantation. The main prognostic factors are the occurrence of concomitant hepatic neoplasms and hepatic encephalopathy. We report two cases diagnosed with a type 1 shunt, hepatic encephalopathy, and associated liver tumors who underwent successful liver transplantation after having considered all therapeutic options.

Since 1963, orthotopic liver transplantation (OLT) has developed into an established interdisciplinary therapy concept for patients with end-stage liver disease, acute irreversible liver failure, and hepatic malignancies in selected cases. In 26 centers in Germany, around 900 full-size OLTs are performed annually. The classic technique has been replaced by the "piggyback" method, which has become the standard in many centres. Improvements in surgical techniques, anaesthetic protocols, and medical management along with the introduction of new immunosuppressive regimens and early adequate therapy against infections and transplant rejection have increased patient survival. These factors have resulted in 1-year survival rates of 80-90% and led to an increase in indications for OLT. Despite decades of experience, approximately 10% of the mortality in the first 3 months still can be traced to technical complications.

Hepatic surgery has grown considerably in importance during the past two decades. Major roles in this development have been played by improvements in imaging diagnostics and intensive care as well as general advancements in hepatic surgical technique. Enormous strides in liver transplantation resulted in new methods also finding use in resective surgery. We present findings on functional and segmental anatomy of the liver on which current hepatic surgery is based, along with technical and oncological aspects requiring consideration for indication. Operative planning and anesthesiological management are discussed.

Surgery is the decisive life-prolonging treatment in patients with hilar cholangiocarcinoma. Surgery is mainly based on empiric data. Since patients without surgery have only about 6 months to survive, to achieve a high resection rate is crucial for these patients. During diagnostic workup, percutaneous transhepatic cholangiography results in the most reliable assessment of longitudinal tumor growth. The extent of the tumor is frequently overestimated leading to the consequence of excluding the patients from surgery. En-bloc resection of the tumor and the adjacent liver should be the preferred surgical approach. So far, surgical radicality (right trisegmentectomy, extended lymphadenectomy and vascular resection) has not been demonstrated to prolong survival. In our experience with 117 patients, median survival of patients following resection was 813 days, whereas patients not amenable to resection survived for 214 days only. Resection rate and the rate of curative resections were 71 and 72 %, respectively, operative mortality was 7 %. In the multivariate analysis, lymph node involvement proved to be the only prognostic marker.

The incidence of pancreatic cancer is increasing. The tumor growths extremely aggressive, long-term prognosis is dismal. Nevertheless, surgical therapy provides the only chance for cure and longterm survival. Achievement of an R0 situation certainly is the primary surgical therapeutic goal. Reduction of surgical radicality in respect to the stomach and the pancreas itself obviously does not influence long-term survival of the patients. Thus, in the majority of patients the pylorus-preserving resection of the head of the pancreas seems to be the best operative strategy for resection of a carcinoma in the head of the pancreas. Concerning lymphadenectomy and resection of the portal or superior mesenteric vein surgical radicality is increasing during the last years. Perioperative mortality after resection of the head of the pancreas could be reduced in high volume centers below 5%. This is true even if parts of the portal or superior mesenteric vein are resected in addition. There are for the first time reports of patients who have survived longer than 5 years after resection of a pancreatic carcinoma. Further improvement of long-term survival, however, will not be achieved by increasing surgical aggressiveness but only by the use of new multimodal therapeutic protocols.

Background: At present, surgical treatment with R(0) resection offers the only chance of cure for patients suffering from pancreatic cancer. Carcinomas of the pancreas are frequently diagnosed at an inoperable stage because of local tumor progression by vessel wall infiltration. In a small series of patients, efforts have been made to increase curative resection rates for advanced pancreatic cancer by excision and reconstruction of the involved visceral arteries. Whether this provides clinical benefit remains uncertain., Methods: Since 2001 we have been employing "en bloc" tumor resection for advanced pancreatic carcinomas with extended infiltration of visceral vessels. Technical experience was gained previously by performing portal vein resection as well as arterial excision and reconstruction by direct anastomosis in the presence of malignant wall infiltration. A total of ten patients underwent vascular reconstruction by arterial homograft interposition. In six of ten cases, combined extended reconstructions of the hepatic and superior mesenteric arteries were performed. One patient died during the perioperative course due to fulminant bleeding. One patient developed severe diarrhea. During a 3- to 18-month follow-up, one case of liver metastasis and one case of local tumor recurrence were documented., Conclusions: In selective cases, operability and R(0) resection can be achieved in advanced pancreatic cancer by performing extended resection procedures with vascular reconstruction using arterial homografts. Vascular substitution of visceral arteries can be conducted without ischemic disturbances of the small bowel and liver. Only a few perioperative complications were observed.

Purpose: To develop a software tool that analyzes the anatomy of the portal vein branches and assigns segmental and subsegmental branches according to Couinaud's classification system and to evaluate its accuracy., Materials and Methods: The algorithm was developed in C++ on a PC. The algorithm recognizes the three major branching patterns of the portal vein. Segmental and subsegmental branches are assigned to 8 segments following Couinaud and encoded by 8 colors. The software was evaluated using CT data sets of 39 patients. After the individual segmental anatomy of each patient was determined by an experienced radiologist, automatic classification was performed and the results were compared on a branch by branch basis., Results: The numbering was accurate according to Couinaud's system in 358 of 409 segmental and subsegmental branches (88 %). The assignment failed in 51 of 409 branches due to unexpected anatomy or software problems., Conclusion: Automatic classification of portal vein branches and their appendant parenchyma is possible. The automatic designation of liver segments enables the three-dimensional visualization of the segmental anatomy. In the future, automatic analysis might facilitate the reporting and communication of CT findings.

Introduction: A two-step procedure is suggested to reduce the overall operative risk in patients with colorectal cancer and large synchronous liver metastases, which demand an extended right hemihepatectomy for R0 resection., Methods: The clinical course and volumetric evaluation of the liver is described in three patients in whom preliminary ligation of the right branch of the portal vein was performed at the time of colon resection., Results: The size of the left lateral lobes increased by 9.9%, 13.7%, and 4.9% of total liver volume, respectively. At the same time, the noninfiltrated part of the right lobes shrunk by 36.7%, 36%, and 6% ukereas metastatic growth was 26.8%, 22.3%, and 12%. After 7 weeks, extended right hemihepatectomy could be performed in all three patients without signs of hepatic insufficiency, yielding R0 resection., Conclusion: Can reduce the risk for extended right hemihepatectomy in selected patients with synchronous colorectal liver metastases.

Transjugular intrahepatic portosystemic shunts (TIPS) are indicated in patients with liver cirrhosis and portal hypertension for treatment of variceal bleeding or refractory ascites. Additionally implantation of stents may lead to stent dislocation or thrombosis in up to 20 % of cases. Detailed information about stent dislocation and its impact on subsequent orthotopic liver transplantation (OLT) is rare regarding the literature. We report on a patient suffering from ethyltoxic liver cirrhosis in which OLT was technically complicated by a thrombosed TIPS stent, dislocated in the portal vein. This stent was implanted prior to OLT due to refractory ascites and partial portal vein thrombosis. We conclude that TIPS stent insertion, especially in liver transplant candidates, should only be performed by radiologists in centers with expertise and experience.

Purpose: Unilateral occlusion of the portal vein induces contralateral lobar hypertrophy - in contrast to complete portal vein occlusion which will result in a cavernous transformation. The impact of the formation of collaterals in partial portal vein occlusion is not sufficiently known. The lobar-hypertrophy- phenomenon is in clinical use for several years to induce iatrogenic liver growth to enable extended resections. After portal vein ligation in patients prior to extended hepatic resections, we noticed a perfusion of the formerly occluded side on CT. Using the well-established mini pig model, we were interested whether portal collaterals are formed as cause of the reperfusion. Ex-situ angiograms of the liver were used for the depiction of collaterals., Materials and Methods: Using a median laparotomy as access for preparation of the hepatoduodenal ligament, a proximal left portal vein ligation was performed in eight mini pigs under general anesthesia. The total arrest of the portal blood flow (except in segments VI and VII) was documented by duplex ultrasound. After 4 weeks, all pigs were sacrificed and the weight of the ligated liver segments and non-ligated liver segments was measured and compared to a sham group (n = 5). After insertion of a guiding sheath, an ex-situ DSA of the portal vein was acquired., Results: Compared with the sham group, the liver weight increased by 60 % (23 - 99 %, std. dev. 30 %) in segments VI and VII. Atrophy of the ligated segments was signified by a weight loss of 10 % (standard deviation 15 %). The ex-situ angiograms revealed a uniform pattern of collaterals with subsequent complete total recanalization of the formerly occluded portal vein distal from the ligation. The collaterals reduced the portal venous flow rate., Conclusion: After portal vein ligation, uniform collateralization results in recanalization of the occluded portal vein. The extent of the collaterals exceeds the known cavernous transformation. The increase in liver volume is not restrained by the formation of collaterals.

Summary. The term "evidence-based medicine" (EBM) - an Anglicism in common use in modern medicine - has of the nature of a catchword, the actual meaning of which is not always clear to all who use it. Generally speaking it is taken to mean that decision-making in the areas of diagnosis and treatment is based on data obtained from randomized, preferably double-blind and controlled, studies involving sufficient numbers of cases. This, however, is not always automatically equatable with arriving at a decision at the highest level of confirmed scientific knowledge, including the most recently acquired facts. Taking account of the current literature, the present article attempts an analysis of the following four aspects of surgical treatment of pancreatic carcinoma: the required extent of lymph node dissection, the relevance of multimodal treatment concepts, the significance of pylorus-preserving partial duodenopancreatectomy and the relevance of portal vein resection.

Hilar resections and hemihepatectomies as surgical strategies for hilar cholangiocarcinoma achieve only limited rates of resectability and radicality. Principles of surgical oncology have to be applied in order to increase the numbers of patients undergoing resection as well as their long-term survival. Due to the anatomical architecture of the hepatic hilum and side-specific variations within the biliary tree, right trisectorectomy and principal portal vein resection have the potential to comply with basic rules of surgical oncology, i.e. wide tumor-free margins and a no-touch dissection technique. In our experience, 5-year survival after formally curative right trisectorectomy and portal vein resection is 65% in spite of advanced tumor stages. Resection of the entire biliary tract without dissection of the tumor is possible by combining total hepatectomy, partial pancreatoduodenectomy and liver transplantation. However, even this procedure does still not fully prevent tumor cell dissemination. So far, a putative alteration of tumor cell kinetics due to posttransplant immunosuppressive treatment results in an increased rate of implantation metastases.

Tumor invasion of the portal vein by ductal adenocarcinoma of the pancreatic head is classically known as a criterion for inoperability. Despite improvement in operation techniques for portal vein resection during Whipple's procedure and acceptable mortality and morbidity, in the case of uncertain tumor infiltration vascular resection cannot be recommended in general. The problem is the preoperative detection of tumor infiltration of the portal vein. Often the surgeon is confronted with unsuspected macroscopic portal vein infiltration or tumor adhesion during the operation. Between 1986 and 1995 105 patients underwent Whipple's procedure for ductal adenocarcinoma of the pancreatic head in our department. In eight of these cases partial portal vein resection was performed because of macroscopic tumor infiltration or tumor adhesion. In all eight cases the preoperative diagnostic procedures with CT and portography did not show any suspicion of tumor infiltration. In four of the eight cases histological tumor infiltration of all vascular layers was found. In the others we found no or only adventitial tumor invasion. The patients without tumor infiltration of the portal vein showed a survival time after surgery of 27.78 months in contrast to 6.67 months in the group with histologically proven tumor infiltration. Endovascular, intraportal ultrasound (IPEUS), a new diagnostic procedure, can give helpful information regarding portal vein involvement. Although the IPEUS is not a standard diagnostic procedure it was shown to detect portal vein infiltration with high sensitivity and specificity. Our results indicate that in such cases where portal vein infiltration has been excluded by IPEUS, patients with macroscopic tumor adhesion do benefit from partial portal vein resection.

Traumatic arterioportal fistulas (APF) are very rare. The most common reasons are liver biopsy and liver injuries. They are also caused by liver tumours and vessel anomalies. This is a case-report of a patient who developed an APF after blunt abdominal trauma. The fistula bearing part of the liver was resected in two sessions. In cases of large APFs with a flow from multiple collaterals the therapy of choice is the embolization. If not possible a selective excision of the fistulous sac or the resection of the fistula containing liver segment are recommended.

The most common cause of portal hypertension in children with healthy livers is the prehepatic block. A 7-year-old girl had presented with portal vein thrombosis after umbilical vein catheterization in the newborn period. She suffered from collateral circulation with recurrent bleeding episodes due to esophageal varices (stage III-IV) and developed hypersplenism. Ultrasound demonstrated an open branch of the left portal vein. Direct splenoportography showed an open and communicating superior mesenteric vein. Liver biopsy was normal. An autologous left jugular vein graft was used to create a bypass from the superior mesenteric vein to the umbilical portion of the left intrahepatic portal vein (mesentericoportal Rex-shunt). Postoperatively, normal intrahepatic portal vein flow was demonstrated by ultrasound. After 2 years of follow-up, the patient is asymptomatic with no signs of portal hypertension. In contrast to classic portosystemic shunt operations, this bypass restores physiological portal vein flow, thus avoiding the possible consequences of longterm portosystemic shunting and low-grade encephalopathy.

Infiltration of the portal vein is almost always regarded as a contraindication for pancreaticoduodenectomy in patients with pancreatic cancer. However, progress in many fields has changed the postoperative situation and mortality of pancreaticoduodenectomy is now below 5%. The aim of the present study was therefore to actually evaluate morbidity, mortality and prognosis of extended pancreaticoduodenectomy combined with protal vein resection for adenocarcinoma of the pancreatic head. Between September 1985 and May 1997 315 patients with a ductal pancreatic carcinoma were treated in our hospital. Resection was possible in 96 cases (partial pancreaticoduodenectomy n = 82, total pancreaticoduodenectomy n = 5, left pancreatic resection n = 9). In 10 cases the portal vein or the mesenteric vein had to be resected. Postoperative complications were seen in 25% of all cases after pancreaticoduodenectomy without portal vein resection and in 20% following extended pancreaticoduodenectomy. The mortality was 5% resp. 0% in both groups. The median survival time of patients after pancreaticoduodenectomy without portal vein resection was 11.9 months (R0 resection: 13.6 months; R1/2 resection 8 months) in contrast to 13.4 months in cases with portal vein resection. In conclusion, these results demonstrate that in special cases of adenocarcinoma of the pancreatic head extended pancreaticoduodenectomy with portal vein resection may be indicated. These patients show a better prognosis than those after palliative procedures. Morbidity and mortality of pancreaticoduodenectomy with portal vein resection is not higher as compared to pancreaticoduodenectomy alone.

Portopulmonary venous anastomosis are a very rare complication of chronic liver diseases. We report on a patient with a cryptogenic liver cirrhosis and thrombosis of the portal vein who underwent antibiotic treatment because of recurrent pneumonias several times. Although treated successfully a pulmonal infiltrate persisted in further radiologic controls. By means of a velocity-encoded MRI a portopulmonary shunt of 30% of the cardiac output was assured. An operative correction with a distal splenorenal shunt was performed successfully. Former reports of portopulmonary anastomoses complicating chronic liver disease never were hemodynamically relevant. In the presented case, a portopulmonary anastomosis lead to recurrent pneumonias and a restrictive ventilatory disorder.

Pylephlebitis, septic thrombosis of the portal vein and its branches, is an infrequent complication of intra-abdominal inflammatory processes which may lead to thrombosis of the portal vein or to liver abscesses. Air in the protal venous system usually predicts a fatal outcome. The survival rate calculated in all reported cases is less than 25%. It is important to detect portal venous gas early. In detection of portal venous gas, ultrasound and computed tomography are more sensitive than plain radiographs. Pylephlebitis used to be a dreaded complication of appendicitis, but the incidence of this disease has greatly declined since the development of antibiotics and modern surgical techniques. We present two cases of pylephlebitis associated with gas in the portal vein as a result of left colonic diverticulitis treated by bowel resection. In spite of the occurrence of portal venous gas, the outcome may be favourable if this disease undergoes prompt surgical treatment.

Thrombosis of the portal system should be ruled out in all patient with esophagogastric varices. Such patients with no evidence of concomitant liver disease and with a high risk of rebleeding (e.g. gastric varices, low platelet counts, endoscopic criteria) should be referred to decompressive shunt surgery. The type of shunt is dictated by the patent segments of the portal system. Splenectomy should be avoided. The results show a low operative mortality, a zero encephalopathy and a low rebleeding rate. Patients with prehepatic thrombosis and liver cirrhosis represent a more severe problem since the risk and mortality of variceal hemorrhage is high and on the other hand TIPS procedure and liver transplantation may be impossible. In case of a high risk of rebleeding or endoscopic therapy failure we advocate surgical shunting as the risk of encephalopathy appears to be low when portal flow diversion already exists.

The infiltration of the portal vein is not considered an absolute contraindication for resection therapy of proximal bile duct carcinomas. Portal vein resection and reconstruction may be performed without additional perioperative risk after hilar resection and hepatectomy. The resected hepatic vein is a suitable material for portal vein reconstruction. The median survival of patients with additional portal vein resection is comparable with patients without vascular infiltration in the same tumor stage.