Backgrounds/Aims: Timing of resection for synchronous colorectal liver metastasis (CRLM) has been debated for decades. The aim of the present study was to assess the feasibility of simultaneous resection of CRLM in terms of major complications and develop a prediction model for safe resections. Methods: A retrospective single-center study of synchronous, resectable CRLM, operated between 2013 and 2021 was conducted. Upper limit of 95% confidence interval (CI) of major complications (≥ grade IIIA) was set at 40% as the safety threshold. Logistic regression was used to determine predictors of morbidity. Prediction model was internally validated by bootstrap estimates, Harrell's C-index, and correlation of predicted and observed estimates. Results: Ninety-two patients were operated. Of them, 41.3% had rectal cancers. Major hepatectomy (≥ 4 segments) was performed for 25 patients (27.2%). Major complications occurred in 20 patients (21.7%, 95% CI: 13.8%-31.5%). Predictors of complications were the presence of comorbidities and major hepatectomy (area under the ROC curve: 0.692). Unacceptable level of morbidity (≥ 40%) was encountered in patients with comorbidities who underwent major hepatectomy. Conclusions: Simultaneous bowel and CRLM resection appear to be safe. However, caution should be exercised when combining major liver resections with bowel resection in patients with comorbid conditions.

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We evaluated a 61-year-old female for a periampullary cancer. The preoperative contrast enhanced CT scan demonstrated an abnormal course of superior mesenteric vein (SMV). The vein was absent from its normal location in the groove behind neck of the pancreas and anterior to the superior mesenteric artery. It was found to be coursing anomalously, posterior to the uncinate process of pancreas and on the right of superior mesenteric artery. This is probably the first report of this anomaly. We had to coin the term ‘retro- uncinate SMV’ to describe this anatomical variation. Rest of the porta structures and pancreas were found to be anatomically normal in this patient. This is a rare anomaly, probably does not have a pathological consequence and remained unreported. Congenital variations in porta structures are relatively common. Careful and thorough preoperative assessment of radiology is essential to have a roadmap to avoid injuries to such anomalous structures during surgery. Preoperative identification of this anomaly resulted in a safe pancreaticoduodenectomy in this patient. Development of portal venous system and pancreas are closely related due to their anatomical proximity. Normally, the left part of ventral pancreatic anlage regresses and right part rotates posterior to the developing SMV. Malrotation of this right ventral pancreatic anlage anterior to the developing SMV or Regression of right ventral pancreatic anlage and persistence and development of left ventral pancreatic analge anterior to the developing SMV is the only logical explanation for development of this anomaly.