Intraoperative ultrasound is a relevant tool for liver surgery. However, dealing with small isoechoic lesions can be challenging in patients with injured livers after chemotherapy or steatosis. We present the case of a 57 years-old male with history of laparoscopic sigmoidectomy for colon cancer two years ago. During follow-up a CT scan revealed a 9-mm deep lesion in segment 5 with elevation of CEA level to 9 ng/mL. This lesion was confirmed with a PET/CT scan but was not visible on liver ultrasound. Considering this as a non-palpable isoechoic lesion difficult for intraoperative detection, a preoperative tumor marking was decided. Before surgery, a CT-guided titanium "coil" placement was performed 2 mm away from the liver metastases with local anesthesia. A laparotomy was performed using a right subcostal incision and using intra-operative ultrasound the "coil" was easily visualized. An in-situ liver splitting was performed through the Cantle plane aiming for a parenchymal preserving approach. Sequential intra-operative ultrasounds were extremely helpful to detect the marked lesion. Finally, the lesion was carefully resected with a negative margin. Saline solution through the cystic duct reveals no bile leaks and intra-operative cholangiography confirmed absence of intra and extra-hepatic bile duct injuries. The patient was discharged on the second postoperative day. To conclude, preoperative CT-guided coil marking for unique small isoechoic liver metastases is a helpful tool and should be incorporated by HPB surgeons dealing with injured livers.

Introduction: An objective assessment of pancreatic fibrosis (PF) to determine the risk of pancreatic fistula after pancreaticoduodenectomy (PD) remains a pending task. We aimed to determine the relation between histopathological PF and pancreatic fistula and to establish the utility of preoperative computer tomography (CT) as predictor of PF. Methods: A consecutive series of patients undergoing PD with histopathological analysis of the grade of PF during the period 2009–2015 were included. The degree of PF was classified in three groups (normal or low, moderate and severe) according to morphological characteristics. Pancreatic duct diameter (PDD) and the ratio of the mean CT attenuation value (hepatic to pancreatic phase; late/early (L/E) ratio) were analyzed as tomographic predictors of PF. Results: A total of 45 patients (median age 61 years) were included. Histopathological analysis showed mild fibrosis in 17 patients (38%), moderate in 17 (38%) and severe fibrosis in 11 (24%). Patients with mild or moderate fibrosis had an incidence of pancreatic fistula of 38.2%, whereas no patients with severe fibrosis presented fistula (p = 0.01). PDD and L/E >1 were positively correlated with pancreatic fibrosis. Conclusions: The grade of pancreatic fibrosis determined by histopathology is a good predictor of pancreatic fistula. The preoperative CT seems to be useful to predict the grade of fibrosis of the pancreatic gland.