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Introduction: Primary sclerosing cholangitis sets the scene for several pathologies of both the intrahepatic and the extrahepatic biliary tree. Surgical treatment, when needed, is almost unanimously summarized in the creation of a Roux-en-Y hepaticojejunostomy, a procedure with a relatively high associated failure rate. Presentation of case: A 70-year-old male, diagnosed with primary sclerosing cholangitis, was submitted to a Roux-en-Y hepaticojejunostomy due to a dominant stricture of the extrahepatic biliary tree. Recurrent episodes of acute cholangitis dictated a workup in the direction of a possible stenosis at the level of the anastomosis. The imaging studies were inconclusive while both the endoscopic and the transhepatic approach failed to assess the status of the anastomosis. A laparotomy, with the intent to revise a high suspicion for stenosis hepaticojejunostomy, was decided. Intraoperatively, a decision to assess the hepaticojejunostomy prior to the scheduled surgical revision, via endoscopy, was made. In this direction, an enterotomy was made on the short jejunal blind loop in order to gain luminal access and an endoscope was propelled through the enterotomy towards the biliary enteric anastomosis. Results: The inspection of the anastomosis under direct endoscopic vision showed no evidences of stenosis and averted an unnecessary, under these circumstances, revision of the anastomosis. Conclusions: The surgical revision of a Roux-en-Y hepaticojejunostomy is a highly demanding operation with an increased associated morbidity, and it should be reserved as the final resort in the treatment algorithm. An approach of utilizing surgery to facilitate the endoscopic assessment prior to proceeding to the surgical revision of the anastomosis appears justified. Full article

Metastatic colorectal cancer is associated with a rather dismal 5-year overall survival. The liver is the most commonly affected organ. Improved 5-year survival rates after successful hepatic resections for metastases confined to the liver have been reported. Certainly, a hepatectomy that results in an incomplete tumor resection, in terms of leaving macroscopic residual tumor in the future liver remnant, is not associated with survival benefits. However, the prognostic implications of a microscopically positive surgical margin or a clear margin of less than 1 mm (R1) on pathology are debatable. Although it has been a field of extensive research, the relevant literature often reports contradictory results. The purpose of the present study was to define, assess the risk factors for, and, ultimately, analyze the effect that an R1 hepatic resection for colorectal cancer liver metastases might have on local recurrence rates and long-term prognosis by reviewing the relevant literature. Achieving an R0 hepatic resection, optimally with more than 1 mm of clear margin, should always be the goal. However, in the era of the aggressive multimodality treatment of liver metastatic colorectal cancer, an R1 resection might be the cost of increasing the pool of patients finally eligible for resection. The majority of literature reports have highlighted the detrimental effect of R1 resections on local recurrence and overall survival. However, there are indeed studies that degraded the prognostic handicap as a consequence of an R1 resection in selected patients and highlighted the presence of RAS mutations, the response to chemotherapy, and, in general, factors that reflect the biology of the disease as important, if not the determinant, prognostic factors. In these patients, the aggressive disease biology seems to outperform the resection margin status as a prognostic factor, and the recorded differences between R1 and R0 resections are equalized. Properly and accurately defining this patient group is a future challenge in the field of the surgical treatment of colorectal cancer liver metastases. Full article