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AIM: To assesse the rate of bile duct injuries (BDI) and overall biliary complications during single-port laparoscopic cholecystectomy (SPLC) compared to conventional laparoscopic cholecystectomy (CLC). METHODS: SPLC has recently been proposed as an innovative surgical approach for gallbladder surgery. So far, its safety with respect to bile duct injuries has not been specifically evaluated. A systematic review of the literature published between January 1990 and November 2012 was performed. Randomized controlled trials (RCT) comparing SPLC versus CLC reporting BDI rate and overall biliary complications were included. The quality of RCT was assessed using the Jadad score. Analysis was made by performing a meta-analysis, using Review Manager 5.2. This study was based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. A retrospective study including all retrospective reports on SPLC was also performed alongside. RESULTS: From 496 publications, 11 RCT including 898 patients were selected for meta-analysis. No studies were rated as high quality (Jadad score ≥ 4). Operative indications included benign gallbladder disease operated in an elective setting in all studies, excluding all emergency cases and acute cholecystitis. The median follow-up was 1 mo (range 0.03-18 mo). The incidence of BDI was 0.4% for SPLC and 0% for CLC; the difference was not statistically different (P = 0.36). The incidence of overall biliary complication was 1.6% for SPLC and 0.5% for CLC, the difference did not reached statistically significance (P = 0.21, 95%CI: 0.66-15). Sixty non-randomized trials including 3599 patients were also analysed. The incidence of BDI reported then was 0.7%. CONCLUSION: The safety of SPLC cannot be assumed, based on the current evidence. Hence, this new technology cannot be recommended as standard technique for laparoscopic cholecystectomy.

Retroperitoneoscopy and the transperitoneal approach are well-established for retroperitoneal procedures. Natural orifice transluminal endoscopic surgery (NOTES) is a rapidly evolving mode of surgical access to body cavities. NOTES has been well-demonstrated in animal models and in (sporadic) human cases for various surgeries.1 In this report, we describe the first human case of transrectal endoscopic retroperitoneoscopy for drainage of a paraaortic periprosthetic abscess.

Purpose: Complicated acute appendicitis is still associated with an increased morbidity. If laparoscopy has been accepted as a valid approach, some questions remain concerning intra-abdominal abscess formation. Routine prophylactic drainage of the abdomen has been proposed. However, this practice remains a matter of debate, poorly validated in the literature. With the present study, we investigated the impact of drainage in laparoscopic appendectomy for complicated appendicitis. Method: This is a case match study of consecutive patients operated on by laparoscopy in a single institution. One hundred and thirty patients operated for complicated appendicitis (local peritonitis without perforation, with perforation, or with periappendicular abscess) with prophylactic intraperitoneal drainage were matched one by one to 130 patients operated without drainage. Uncomplicated appendicitis and generalized peritonitis were excluded. Primary endpoint was surgical complications and secondary endpoints were transit recovery time and length of hospital stay. Results: Patients without drain had significantly less overall complications (7.7% vs. 18.5%, p = 0.01). Moreover, the absence of drainage was of significant benefit for transit recovery time (2.5 vs. 3.5days, p = 0.0068) and length of hospital stay (4.2 vs. 7.3days, p

Promising new technologies are emerging in digestive surgery: Natural Orifice Transluminal Endoscopic Surgery (NOTES) and Single Port Access Surgery. They both aim to limit the surgical morbidity by decreasing the number of parietal accesses. The feasibility in human is obviously demonstrated, but numerous issues remain concerning the safety of these techniques. Furthermore, the expected advantages are not clearly demonstrated until now in the literature. In the future, it will be advisable to standardize techniques, in order to allow large clinical studies and to limit the potential complications of these approaches.

AIM: To develop a pure transvaginal access to the retroperitoneum, that is simple, reproducible and uses endoscopic material available on the market. METHODS: From February 2008 to April 2009, 31 pigs were operated on, with 17 as an acute experiment and 14 with a survival protocol. The animals were placed in a supine position and a 12-mm double-channel endoscope (Karl Storz™, Tuttlingen) was used for vision and dissection. During the same time period, the access experiment was reproduced on 3 human cadavers using material similar to that used in the animal model. RESULTS: In the animal model, 37 interventions were done on the kidney, adrenal gland and pancreas. The mean time to fashion the access was 10 min (range 5 to 20 min). No intraoperative death was observed. Two major (5%) intraoperative complications occurred: one hemorrhage on the aorta and one tearing of the right renal vein. Peritoneal laceration was encountered in 5 cases without impairing the planned task. In the survival group, good clinical outcome was observed at a mean follow-up of 3 wk (range 2 to 6 wk). In the 3 cadavers, access was performed correctly. The mean time to fashion the access was 52 min (range 40 to 60 min). All the anatomical landmarks described in the pig model were clearly identified in the same sequence. CONCLUSION: A retroperitoneal natural orifice translumenal surgical transvaginal approach is feasible in both animal and human models and allows performance of a large panel of interventions.

It is generally accepted that the most effective treatment of achalasia is a surgical myotomy. Nevertheless, if a myotomy alone is performed, reflux may occur in up to 30% of patients. The aim of this study was to explore a transoral incisionless stepwise approach to both esophageal Heller myotomy and fundoplication.The first step consisted of creating the esophageal myotomy. Under general anesthesia, with the pig supine, endoscopy was performed to assess the location of the esophagogastric junction (EGJ). The mucosa on the right posterolateral esophageal wall was cut with the needle-knife 15 cm above the lower esophageal sphincter (LES) and then dilated with blunt dissection to introduce the scope. A submucosal tunnel was created distally with CO(2) and blunt dissection. Once the gastroesophageal junction (GEJ) and the clasp fibers were identified, the muscular layer was cut. The scope was withdrawn into the lumen and the mucosal flap was sealed with endoscopic clips. The adequacy of the myotomy was evaluated using pre- and postoperative manometry and by comparing the EGJ distensibility before, during, and after the division of the esophageal muscular fibers using the functional lumen imaging probe, EndoFLIP®. The second step, consisted of building a transoral incisionless fundoplication 4 weeks postoperatively using the EsophyX™.Both Heller myotomy and endoscopic fundoplication were accomplished successfully with no injury to the esophageal mucosa. Postoperative manometry demonstrated a 50% loss in mean LES pressure (mean preoperative LES pressure = 22.2 mmHg; mean postoperative LES pressure = 10 mmHg, P0.005). The EndoFLIP® showed a preoperative minimal diameter of 6 mm with a cross-sectional area of 28 mm(2). Postoperatively, the junction was more compliant (minimal diameter = 15 mm; cross-sectional area = 177 mm(2)), with the main improvement in distensibility occurring when the clasps fibers were removed.A stepwise transoral incisionless approach to esophageal Heller myotomy and partial fundoplication is feasible and effective in the porcine model. A distensibility test such as the EndoFLIP® may provide better information on the opening and closing dynamics of the EGJ, rather than just relying on the sphincter tonic state as measured by manometry.

Background Single port access (SPA) cholecystectomy is a new concept in laparoscopic surgery. A review of existing results was performed to evaluate critically the current state of SPA with specific reference to feasibility, safety, learning curve, indications and cost-effectiveness. Methods All papers identified in MEDLINE until 15 February 2010 and all other relevant papers obtained from cited references were reviewed, without any language restriction. Case reports and series of fewer than three patients were excluded. Results After selection, 24 studies including 895 patients were analysed. None was randomized. Feasibility seems to be established, with a conversion rate of 2 per cent. SPA was not standardized and there was much technical variation. The learning curve could not be determined. Median follow-up time was 3 (range 0·25–12) months. The overall published complication rate was 5·4 per cent and the biliary complication rate 0·7 per cent. The rate of umbilical complications ranged from 2 to 10 per cent. Conclusion SPA cholecystectomy seems feasible, but standardization, safety and the real benefits for patients need further assessment. Uncontrolled wide adoption of this approach may be responsible for a rise in biliary complications.

Background Clinical application of natural orifice transluminal endoscopic surgery is under investigation. Preliminary results of transvaginal cholecystectomy in women and associated technical issues have been described. The technique and initial results of hybrid transgastric cholecystectomy are now reported. Methods Five patients aged 18–60 years with uncomplicated cholelithiasis underwent transgastric cholecystectomy in a prospective intention-to-treat study that included the option of transparietal assistance (hybrid technique) if needed. The gastrotomy was created under laparoscopic guidance through a 5-mm umbilical trocar, which also served to expose the gallbladder, clip the cystic pedicle and close the gastrotomy. Cholecystectomy was carried out using flexible instruments through the endoscope, alone or in combination with laparoscopic instruments. Results The procedure was successful in all patients with a median operating time of 150 (range 120–180) min. Transparietal assistance was necessary in all patients. There were no intraoperative or postoperative complications. Conclusion Until technical issues have been resolved, a hybrid procedure with liberal use of transparietal assistance is the safest and most efficient approach for transgastric cholecystectomy. Further studies are essential to evaluate the role of this new approach.

It is well known in clinical medicine that palpation is an effective diagnostic tool for characterizing tissues mechanical properties. This accounts for the motivation of investigators for developing quantitative elastography techniques for noninvasively evaluating the viscoelastic properties of tissues. Comparison of a new clinical measurement technique with an established one is often needed to determine whether they agree sufficiently. Dynamic Mechanical Analysis (DMA) is often considered as the reference method to characterize quantitatively mechanical properties of materials. However, DMA is an invasive technique and only in vitro mechanical properties can be estimated. In this study, a comparison between Vibration-Controlled Transient Elastography (VCTE™) and Dynamic Mechanical Analysis techniques is performed on in vivo / in vitro porcine liver. In vitro results show that elastic properties obtained by VCTE™ and DMA are in agreement. Results demonstrate that the liver is homogeneous, isotropic and more elastic than viscous. Besides, it is presented that viscoelastic properties obtained by VCTE™ and DMA change significantly with postmortem time and with the boundary conditions. Finally, this work shows that VCTE™ could be the new “gold standard” method for quantitatively assessing in vivo tissue elastic properties.

The retroperitoneal approach preserves the peritoneal cavity and its envelope. The benefits of laparoscopic retroperitoneal approach to the kidney and the adrenal gland are well known. The pancreas may represent another potential target. Whereas NOTES transperitoneal distal pancreatectomy has been reported, the retroperitoneal approach, which may combine the advantages of peritoneal preservation with those of no scar surgery, has never been explored. We report the feasibility of NOTES transvaginal retroperitoneal pancreatectomy in a porcine model.With the pig supine, under general anesthesia, a 10-mm posterior colpotomy was performed with a needle-knife operated through a flexible 12-mm, double-channel endoscope (Karl Storz). A retroperitoneal tunnel was created with blunt dissection up to the left kidney with progressive visualization of the left iliac vessels, ureter, and abdominal aorta. To reach the posterior aspect of the pancreas, a space was opened medial to the upper renal pole dividing the Gerota's fascia. The tail of pancreas was mobilized with blunt and sharp dissection, using monopolar cautery. Once the distal pancreas was dissected free, it was secured using a polypropylene endoscopic loop and then resected with an endoscopic snare (Olympus).The procedure was successfully accomplished by a totally NOTES approach in five pigs, with a mean operative time of 118 (range, 105-185) minutes with no intraoperative complications and no injury to any retroperitoneal structure.The pancreas is accessible by a transvaginal retroperitoneal NOTES approach. Human cadavers studies are necessary to confirm the validity of this model and to explore the need for specific technological developments, such as flexible stapling devices, to improve the safety of pancreatic resection.

Introduction Les rapports plaquettes/lymphocytes et neutrophiles/ lymphocytes ont ete etudies comme parametres representatifs de la reponse inflammatoire systemique chez les patients oncologiques. Notre etude visa a evaluer le rapport plaquettes/leucocytes (RPL) pour le cancer de l’œsophage, et d’analyser la correlation avec la reponse histologique au traitement neoadjuvant (NAT) selon Mandard, les complications majeures postoperatoires et la survie globale. Methode Tous les patients operes d’une œsogastrectomie pour cancer dans notre centre entre 2000 et 2013 ont ete etudies. Une analyse ROC a ete conduite pour estimer la valeur seuil optimale du RPL et comparer les parametres principaux entre les differents sous-groupes. Le test de Fisher et ANOVA ont ete utilises pour les valeurs categoriques et continues respectivement, avec une valeur p Resultats Nous avons analyses 132 patients avec un âge median de 64 [46-84] ans, dont 59 (44,7 %) ont eu un traitement neoadjuvant. Le RPL pretraitement n’a pas ete predictif de la survenue des complications majeures postoperatoires ni de la survie globale des patients. En revanche, un RPL>22 a ete significativement correle a une reponse histologique complete ou excellente (TRG 1-2) apres NAT. Conclusion Un RPL>22 avant traitement neoadjuvant pour le cancer de l’œsophage a ete significativement correle a une reponse histopathologique complete ou excellente. Declaration d’interet Les auteurs n’ont pas transmis de conflits d’interets.

Introduction Les programmes ERAS ont recemment ete etendus a la chirurgie hepatique, mais l’experience rapportee est limitee et les effets cliniques pas clairement etablis. Le but de ce travail est de comparer les resultats a court terme d’un programme de rehabilitation rapide en chirurgie hepatique a une prise en charge standard. Methodes Depuis juillet 2013, les patients admis pour resection hepatique ont ete inclus dans un programme de rehabilitation rapide, sans aucune selection. La prise en charge etait basee sur les recommandations ERAS colorectale et discutee en reunion multidisciplinaire (chirurgiens, anesthesistes, infirmieres specialisees). Observation En six mois, 32 patients ont ete inclus dans notre programme (groupe ERAS) et compares a 71 patients operes en 2012, ayant beneficie de soins standards. Les deux groupes etaient semblables en termes d’âge moyen (67 ans vs 63, p = 0,36) et de taux de resection majeure (27 % vs 38 %, p = 0,4). Le taux de complication a 30 jours etait plus faible dans le groupe ERAS (16 % vs 32 %, p = 0,032), de meme que la duree de sejour (7 jours vs 16, p = 0,0037). Conclusion L’implementation d’un programme ERAS aux resections hepatiques est faisable, meme pour des cas non-selectionnes. Ces resultats preliminaires montrent une diminution du taux de complication et de la duree de sejour. Cependant, des donnees plus completes et une observation plus longue sont necessaire afin de confirmer ces resultats encourageants.

Introduction La resection rectale robotisee est controversee. Ses avantages techniques (precision, exposition) pourraient etre deci-sifs dans un pelvis etroit, mais les avantages cliniques reels sont encore debattus. Le but de ce travail est de comparer la qualite de l’excision totale du mesorectum (TME) pour cancer entre la chirurgie robotique et la chirurgie laparoscopique. Methodes Dix-huit patients consecutifs operes a l’aide du robot Da Vinci ont ete apparies a 36 patients operes par laparoscopie, selon le sexe, l’indice de masse corporelle et la distance par rapport a la marge anale (appariement 1:2). La qualite de la TME a ete eva-luee par deux pathologues experimentes et rapportee selon les recommandations internationales. Observation Les deux groupes etaient similaires en terme de temps operatoires (5 h 13 vs 4 h 51, p = 0,24) et de taux de complication (50 % vs 38 %, p = 0,3). La qualite de la TME etait superieures dans le groupe robotique (TME complete : 94 % vs 51 %, p = 0,001 ; TME quasi-complete : 5 % vs 37 %, p = 0,04). Dans ce meme groupe, le taux de marge de resection circonferentielle (CRM) positive sem-blait plus faible (14 % vs 34 %), sans etre statistiquement significative (p = 0,14). Conclusion Ces resultats preliminaires suggerent que la chirurgie laparoscopique robotique pourrait ameliorer la qualite de l’excision totale du mesorectum pour cancer. Cependant, de plus amples investigations sont necessaires pour demontrer si cet effet se traduira par un avantage oncologique.

Several working groups have already demonstrated the feasibility of transgastric surgery procedures using flexible endoscopes. However, technical limitations in natural orifice translumenal endoscopic surgery (NOTES) (e.g., exposure, retraction, insufflations, and triangulation) currently still require the use of at least one external instrument [1–3]. Therefore, “pure NOTES” transgastric cholecystectomy has not yet been described. The authors successfully performed “pure NOTES” transgastric cholecystectomy using a transoral dual-scope technique (similar to the approach the authors previously reported for gastric closure [4]) that allows completion of the procedure by pure NOTES without an external instrument. With the subject under general anesthesia, a double-channel gastroscope (Storz®, Tuttlingen, Germany) passed by mouth entered the peritoneum through the distal anterior gastric wall. The most ideal site for a second gastric exit was then selected for another single-channel scope. With the gallbladder retracted by the assistant operating the double-channel scope, retrograde cholecystectomy was performed by the primary surgeon using the single-channel scope. Four animals were killed immediately to study the quality of the operative dissection, whereas the other four pigs were kept alive. The gastrotomy was closed using a 27- to 30-mm cardiac septal occluder (Occlutech®, GmbH, Jena, Germany) according to a previously described method [5]. The postoperative follow-up assessment of these animals included laparoscopy and necropsy 2 weeks later. All the cholecystectomies were immediately successful without any intraoperative complication. Scope withdrawal caused no injuries to the esophagus or pharynx. Although no overt postoperative complication was evident, two surviving pigs had signs of minor peritoneal infection. This study investigated “pure NOTES” transgastric cholecystectomy using tentative experimentation to overcome the “retraction” and “triangulation” issues and to realize a “pure NOTES” operation. The use of two endoscopes with selected differentiation of their gastric placements compensated for the lack of triangulation and retraction.

Background The retroperitoneal approach preserves the peritoneal cavity and its envelope. The benefits of laparoscopic retroperitoneal approach to the kidney and the adrenal gland are well known. The pancreas may represent another potential target. Whereas NOTES transperitoneal distal pancreatectomy has been reported, the retroperitoneal approach, which may combine the advantages of peritoneal preservation with those of no scar surgery, has never been explored. We report the feasibility of NOTES transvaginal retroperitoneal pancreatectomy in a porcine model.

Objective To compare laparoscopic and robotic-assisted single-trocar access (STA) Nissen fundoplication in a porcine model. The STA procedure is an emerging concept in minimally invasive surgery that presents technical difficulties and challenges compared with traditional laparoscopy. Using multiple instruments inserted through a single trocar generates internal and external conflicts. Achieving triangulation requires the instruments and surgeon's hands to cross over at the point of entry. Robotic-assisted surgery may overcome these difficulties owing to its capability of dissociating the hands of the surgeon from the instruments. Design Prospective study consisting of 18 randomly performed porcine STA Nissen fundoplications with and without robotic assistance. Setting A research institute. Participants Three surgeons with different experience. Main Outcome Measures Operative time, intraoperative complications, and the number of conflicts between the instruments and/or hands of the surgeons. Results All of the procedures were successfully completed. Mean operative time (45.6 ± 11.2 vs 65.4 ± 10.7 minutes; P = .03) and number of conflicts (1.0 ± 0.9 vs 3.8 ± 1.2; P Conclusions Use of the robotic platform allows the surgeon to select which hand will move which instrument. Inverting the control allows crossing of the instruments without any consequences to the surgeon. Moreover, this system offers instruments with multiple degrees of freedom. These factors could explain the clear improvement demonstrated in this study. As a result, robotics may play an essential part in the diffusion of STA surgery.

After the first report by Kalloo et al on transgastric peritoneoscopy in pigs, it rapidly became apparent that there was no room for an under-evaluated concept and blind adoption of an appealing (r)evolution in minimal access surgery. Systematic experimental work became mandatory before any translation to the clinical setting. Choice and management of the access site, techniques of dissection, exposure, retraction and tissue approximation-sealing were the basics that needed to be evaluated before considering any surgical procedure or study of the relevance of natural orifice transluminal endoscopic surgery (NOTES). After several years of testing in experimental labs, the revolutionary concept of NOTES, is now progressively being experimented on in clinical settings. In this paper the authors analyse the challenges, limitations and solutions to assess how to move from the lab to clinical implementation of transgastric endoscopic cholecystectomy.

Endoscopic adrenalectomy currently is performed using either a retroperitoneal or transperitoneal approach. The retroperitoneal approach is ideal for patients with small lesions who have undergone previous intraabdominal surgery. This study aimed to explore transvaginal retroperitoneal right and left adrenalectomies in porcine and cadaver models. Right and left adrenalectomies were performed for two female pigs. With the pig supine under general anaesthesia, the retroperitoneal space was entered with a double-channel endoscope (Storz) through a posterior colpotomy. A retroperitoneal tunnel was fashioned using blunt dissection with the assistance of low carbon dioxide insufflation up to the inferior pole of the kidney. Dissection of the upper renal pole allowed access to the adrenal gland. Using blunt dissection, a plane was created between the aorta on the left and the adrenal gland and inferior vena cava on the right. The left main middle vascular pedicle was identified and taken between clips, whereas an endoloop was used on the right side. The specimen was retrieved intact with a polypectomy snare. The same access then was reproduced with two female cadavers. Transvaginal retroperitoneal adrenalectomies were successfully accomplished with a transvaginal approach using natural orifice translumenal endoscopic surgery (NOTES). The operative time was 70 min, and there was no injury to the retroperitoneal structures. The access was effectively reproduced in the cadaver model, with prompt identification of the retroperitoneal anatomic landmarks. Transvaginal retroperitoneal NOTES adrenalectomy is feasible in the porcine model. It reaches the adrenal proper anatomic plane with no need for dissection or retraction of the surrounding organs. This technique might be especially valuable for patients with multiple previous abdominal operations and obese patients in that allows direct access to the adrenal gland and minimizes the cardiovascular and pulmonary risk related to carbon dioxide pneumoperitoneum. Although the operation was successfully validated with cadavers, further experiments and better tools are needed before NOTES transvaginal retroperitoneal access is considered for humans.

Esophago-gastric cancer remains a relatively rare pathology with, however, an ascending tendency in the recent years due to a variety of predisposing factors. An extensive preoperative workup and a thorough multidisciplinary discussion are the key elements to define treatment strategy. Surgery is the cornerstone of treatment for resectable tumors, even if it is associated with morbidity rates of 40-60% in medium and high-volume centers. Long-term consequences (e.g. malnutrition and late anastomotic stenosis) are present in a high proportion of patients and they raise the need for a close follow-up with the collaboration of the general practitioner, surgeon and oncologist. This multidisciplinary treatment and aftercare has the best chance to offer to the patient not only a longer overall survival, but a better quality of life as well.

Ga-NODAGA-RGDyK(cyclic) and FDG PET/CT were performed in a 39-year-old man for the work-up of a moderately differentiated carcinoma of the gastro-esophageal junction within a clinical study protocol. Although FDG PET images showed intense, diffuse hypermetabolic lesion activity, NODAGA-RGDyK illustrated the neo-angiogenesis process with tracer uptake clearly localized in non-FDG-avid perilesional structures. Neo-angiogenesis is characterized by ανβ3 integrin expression at the lesion surface of newly formed vessels. This case supports evidence that angiogenesis imaging might therefore be a crucial step in early disease identification and localization, metastatization potential, and in monitoring the efficacy of antiangiogenic therapies.

Background and Objectives: Serum albumin perioperative decrease (∆Alb) may reflect the magnitude of the physiological stress induced by surgery. Studies highlighted its value to predict adverse postoperative outcomes, but data in esophageal surgery are scant. This study aimed to investigate the role of ∆Alb to predict major complications after esophagectomy for cancer. Methods: Multicenter retrospective study conducted in five high-volume centers, including consecutive patients undergoing an esophagectomy for cancer between 2006 and 2017. Patients were randomly assigned to a training (n = 696) and a validation (n = 350) cohort. Albumin decrease was calculated on postoperative day 1 and defined as ΔAlb. The primary endpoint was major complications according to Clavien classification. Results: In the training cohort, esophagectomy induced a rapid drop of albumin. Cut-off of ΔAlb was established at 11 g/L and allowed to distinguish patients with adverse outcomes. On multivariable analysis, ΔAlb was identified as an independent predictor of major complications (OR, 1.06; 95% CI, 1.01–1.11; p =.014). Higher BMI and laparoscopy were associated with lower ΔAlb. Analysis of the validation cohort provided consistent findings. Conclusions: ΔAlb appeared as a promising biomarker after oncological esophagectomy, allowing prediction of potential adverse outcomes.

Background Extrahepatic Portal vein aneurysm (EPVA) is a rare finding that may be associated with different complications, e.g. thrombosis, rupture, portal hypertension and compression of adjacent structures. It is being diagnosed more frequently with the advent of modern cross-sectional imaging. Our review of the English literature disclosed 13 cases of thrombosed EPVA. Case presentation A 50-years-old woman presented with acute abdominal pain but no other symptom. She had no relevant medical history. Palpation of the right upper quadrant showed tenderness. Laboratory tests were unremarkable. A computed tomography showed portal vein aneurysm measuring 88 × 65 mm with thrombosis extending to the superior mesenteric and splenic vein. The patient was treated conservatively with anticoagulation therapy. She was released after two weeks and followed on an outpatient basis. At two months, she reported decreased abdominal pain and her physical examination was normal. A computed tomography was performed showing a decreased thrombosis size and extent, measuring 80 × 55 mm. Conclusions Although rare, surgeons should be made aware of this entity. Complications are various. Conservative therapy should be chosen in first intent in most cases. We reported the case of the second largest thrombosed extra-hepatic PVA described in the literature, treated by anticoagulation therapy with a good clinical and radiological response.